ARBOR VIEW NURSING AND REHABILITATION
For profit - Limited Liability company
150 Beds
VERTICAL HEALTH SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
18/100
#324 of 479 in MO
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Families considering Arbor View Nursing and Rehabilitation should be aware that the facility has received a Trust Grade of F, indicating significant concerns about care quality. It ranks #324 out of 479 facilities in Missouri, placing it in the bottom half, and #9 out of 11 in Jefferson County, suggesting that only one local option is slightly better. The situation is worsening overall, with issues increasing from 11 in 2024 to 19 in 2025. Staffing is a weakness, with only 1 out of 5 stars, although the turnover rate is slightly below the state average at 56%. Notably, the facility has faced $42,770 in fines, which is concerning, and it has been cited for serious deficiencies, including failing to properly isolate COVID-19 positive residents, potentially increasing the risk of infection among all residents.
- Trust Score
- F
- In Missouri
- #324/479
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $42,770 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 54 deficiencies on record. Higher than average. Multiple issues found across inspections.
18/100
Bottom 33%
Review needed
11 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 19 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 56%
10pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $42,770
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: VERTICAL HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Missouri average of 48%
The Ugly 54 deficiencies on record
1 life-threatening
Apr 2025
18 deficiencies
CONCERN
(D)
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 observation, interview, and record review, the facility failed to create an environment that was respectful of the righ...
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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 create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant by providing a bathing schedule based on staff preference and not resident preference for one resident (Resident #1) and by failing to honor one resident's (Resident #24) preference to be shaved daily out of 18 sampled residents . The facility's census was 86.
Review of the facility's policy titled, Resident Rights, Dignity and Visitation Rights, dated 04/01/22, showed:
- It will be the policy of this facility that employees shall treat residents with kindness, respect, and dignity. The facility promotes the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems, and cognition limits) in the exercise of these rights. The facility will ensure the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability;
- Residents are entitled to exercise their rights and privileges to the fullest extent possible;
- The facility will make the effort to assist each resident in exercising his/her rights to assure the resident is always treated with respect, kindness, and dignity; providing care that is comfortable and consistent with his/her normal life habits; observing resident's choices whenever able;
- The facility will promote care for residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his/her individuality, preferences, activities, pursuits, goals, and desires;
- The facility will provide for residents and reception of services with reasonable accommodation of resident needs and preferences except when to do so would endanger the health of safety of the resident or other residents;
- The right to participate in the development and implementation of his/her person-centered plan of care, including but not limited to: the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process; the right to request meetings and the right to request revisions to the person-centered plan of care; the right to participate in establishing the expected goals and outcomes of care; the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care; the right to be informed, in advance, of changes to the plan of care; the right to receive the services and/or items included in the plan of care; the right to see the care plan, including the right to sign after significant changes to the plan of care;
- The facility will encourage and assist residents to dress in their own clothes appropriate to the individual choices of the resident;
1. Review of Resident #1's medical record showed:
- admission date of 09/16/16;
- Diagnoses of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in actives), pain in the left lower leg, non-pressure chronic ulcer of the left lower leg with the fat layer exposed (a sore that takes more than two weeks to heal), hypothyroidism (underactive thyroid disease), generalized anxiety disorder (mental health condition characterized by persistent and excessive worry and anxiety about a wide range of everyday events), and cellulitis (a common bacterial infection of the skin and underlying tissues).
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated , 02/12/25, showed:
- Cognitively intact;
- Activities and preferences not completed;
- Dependent on staff for assistance with personal hygiene and required substantial/maximal assistance with bathing and showering.
Review of the resident's Skin Monitoring: Comprehensive Certified Nurse Assistant (CNA) Shower Review Sheets, dated February and March 2025, showed:
- Resident refused shower/bath on 02/07/25, 02/11/25, 02/18/25, 03/04/25, 03/07/25, 03/11/25, 03/14/25, 03/19/25, 03/25/25, and 03/28/25;
- Resident received a shower/bath on 02/25/25 and 03/21/25;
- No documentation staff offered a shower/bath after the resident refused at a specific time/date.
During an interview on 04/02/25 at 12:55 P.M., Resident #1 said staff asked him/her to shower at times when he/she was in pain or during activities. Activities were one of the few times he/she had to socialize with other residents. The staff would only ask the resident one time to shower/bathe and would document refused if the resident didn't want to right then. The staff didn't come back later at a more convenient time for the resident.
2. Review of Resident #24's medical record showed:
- admission date of 07/13/18;
- Diagnoses of unspecified injury at unspecified level of cervical spinal cord (injury to the neck); quadriplegia (paralysis); spinal muscular atrophy unspecified (deteriorating muscles); and contracture of the right shoulder, the right elbow and the right wrist (shortening and hardening of the muscles, tendons or other tissue).
Review of the resident's quarterly MDS, dated [DATE], showed:
- Cognitively intact;
- Activities and preferences not completed;
- Dependent on staff for assistance with personal hygiene, bathing, and showering.
Observation on 03/30/25 at 11:32 A.M., 03/31/25 at 1:16 P.M., and 04/02/25 at 12:55 P.M., of the resident showed:
- Whiskers/stubble on resident's chin.
During an interview on 03/31/25 at 1:30 P.M. Resident #24's two roommates said they had to shave the resident because the staff won't shave him/her.
During an interview on 04/02/25 at 1:21 P.M., Resident #24 said the staff would not shave him/her. Only times he/she was shaved was when his/her roommates did it. He/She preferred to keep a clean shaven chin daily and did not like it when he/she was not able to do so.
During an interview on 04/02/25 at 1:30 P.M., the Administrator said she would expect residents to be able to have the right to make their own decisions regarding if they want to be shaved and when they were showered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a final accounting of a resident's fund balance within 30 d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a final accounting of a resident's fund balance within 30 days to the individual or probate jurisdiction administering the resident's estate for one expired resident (Resident #87) out of one expired resident. The facility census was 86.
The facility did not provide a policy regarding resident funds balance.
Review of Resident #87's medical record showed:
- The resident expired on [DATE].
Record of the facility maintained Trust Trial Balance, dated [DATE], showed:
- Resident #87 with an account balance of $2,694.
During an interview on [DATE] at 9:03 A.M., the Social Services Designee (SSD) said normally if someone passed away, their money would go towards any funeral home bills. If the resident had a financial power of attorney (POA), then they would get them a check for the balance and if not, they would send the money to the state. The facility tried to do this process within a week of a death.
During an interview on [DATE] at 9:24 A.M., the Administrator said she would expect remaining resident funds to be sent to the appropriate party within 30 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to monitor and keep one resident's (Resident #54) equipment in good, working order. The facility also failed to provide a safe, ...
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Based on observation, interview, and record review, the facility failed to monitor and keep one resident's (Resident #54) equipment in good, working order. The facility also failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 86.
The facility did not provide a policy regarding a safe, clean, comfortable, and homelike environment.
The facility did not provide a policy regarding maintenance of residents' equipment.
1. Observation on 03/30/25 at 10:56 A.M., of Room C9 showed:
- A window unit below the window with drywall placed around the top and both sides that did not completely in case the window unit. There were open areas to the top and right side of the unit with light from the outside that showed around the top of the unit. There was insulation pushed in an open area directly above the window unit to cover a gap from the window unit to the drywall nailed in place around the window unit. The top opening was approximately 32 inches (in) by 1 in and the right-side opening was approximately 20 in by 0.5 in.
2. Observation of the dining room on 03/30/25 at 11:30 A.M., showed:
- The wall beneath the kitchen windows with red, green, and brown splatters on it;
- Approximately two feet of baseboard trim missing underneath the dining room kitchen window;
- Approximately 6 inches of baseboard trip missing next to the left exit door;
- Three ceiling tiles with dark brown/black substance close to the left exit door.
3. Observation on 03/30/25 at 12:30 P.M., of Room B10 showed:
- Four holes in the wall above the bed next to the door;
- Paint chipping off the wall over the bed next to the window;
- Black scuff marks along the wall and bathroom door;
- The window unit missing vents inhibiting the resident's ability to control the direction of the air flow;
- The closet door broken and unable to stay closed;
- The bathroom door latch/handle broken and unable to stay closed.
During an interview on 03/30/25 at 12:30 P.M. the resident in Room B10 said he/she was unhappy with his/her room. The bathroom door handle had been broken for a long time and would not close or latch. He/She purchased some velcro tape to put on the door, so it would stay closed. However, since the door did not latch, there was no way to ensure his/her privacy. He/She had to do the same thing to the closet door because it was broken and would not stay closed. The room needed to be repainted due to all the black scuff marks and the paint chipped off the walls. The air conditioner also needed to be fixed or replaced. It bothered him/her that the vents were missing, because without the vents, the direction of the air flow couldn't be controlled.
4. Observation on 03/30/25 at 2:07 P.M., of Resident # 54's wheelchair showed:
- Both arms of the wheelchair with cracked and ripped vinyl;
- The right wheelchair arm with pieces of peeling duct tape around the end of the ripped area.
During an interview on 03/30/25 at 2:07 P.M., Resident # 54 pointed to the arms of his/her wheelchair and said the cracked and ripped vinyl bothered him/her and wanted it replaced or fixed.
5. Observation on 03/30/25 at 2:31 P.M., of Room B8 showed:
- A brown area on the ceiling in front of the window next to the privacy current railing approximately 12 inches wide;
- The window unit with missing vents;
- The drywall of the window ledge chipped and crumbling into pieces;
- The bathroom door handle/latch broken.
During an interview on 03/30/25 at 2:31 P.M., the resident in Room B8 said he/she was upset the bathroom door handle was broken and he/she had no way to ensure privacy when using the bathroom. It was embarrassing when someone would accidentally open the door. He/She was not happy with the way the area around the window unit was. The window seal had been messed up for a long time and the air unit had been missing the vents for a long time.
6. Observation on 03/30/25 at 2:36 P.M., of Room B6 showed:
- The right edge of the curtain hung loose from the window;
- The closet door was missing;
- The air unit was missing vents.
7. Observation on 03/30/25 at 3:24 P.M. of Room D8 showed:
- Paint peeled off the wall around the air conditioning unit;
- The ceiling vent in the bathroom covered in dust.
8. Observation on 03/31/25 at 8:14 A.M., of Room B3 showed:
- The closet door was missing;
- The window seal and area around the air unit with chipped drywall, marks, and exposed unpainted areas with gray caulking.
During an interview on 04/02/25 at 10:30 A.M., the Maintenance Director said that he/she was unaware of the window unit in Room C9 had any openings to the drywall around the window unit.
During an interview on 04/02/25 at 10:40 A.M., the Administrator said that she would expect window units to be properly placed and not be able to see daylight from inside a resident's room with gaps around the unit in the drywall.
During an interview on 04/02/25 at 1:45 P.M., the Administrator said she would expect the facility to have a homelike environment and things to be repaired as needed. There was a maintenance log book that anyone could write things that need to be repaired. Normally the repair time should be within a few days even if it's something that had parts that need to be ordered for the repairs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, for five residents (Residents #11, #12, #38, #46, and #59) out of 18 sampled residents and one resident (Resident #44) outside the sample. The facility's census was 86.
Review of the facility policy titled, Transfer and Discharge, dated 04/01/22, showed:
- It is the policy of this facility to provide appropriate transfer and discharge services, documentation that will be included in the medical record, and who is responsible for making the documentation. The facility will allow for sufficient preparation and orientation by informing the resident where he/she is going to take steps to minimize anxiety;
- The Notice of Transfer or Discharge should be made by the facility at least 30 days before the resident is transferred or discharged except under the following circumstances and the Notice must be made as soon as practicable before transfer or discharge when: the safety of individuals in the facility would be endangered; the health of individuals in the facility would be endangered; the resident's health improves sufficiently to allow a more immediate transfer or discharge; an immediate transfer or discharge is required by the resident's urgent medical needs; or a resident has not resided in the facility for 30 days;
- When a change in condition or required transfer to the hospital or other higher level of care is determined, the facility should obtain appropriate transfer orders from the physician;
- Documentation of the change of condition or required transfer should be reflected in the medical record;
- Appropriate documentation and forms will be sent to the receiving facility/accompany the resident during transport and attempt to have them signed by the resident/resident representative should be made. The forms can include such items as the Bed Hold policy, Transfer Discharge Notification, listing of current medications/treatments, face sheet, and other forms that may be appropriate if activated;
- Notification of the resident's representative should be denoted in the medical record as is appropriate per the resident's capacity and choice, if applicable;
- In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative, and will also send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman;
- If the resident transfers to another facility or the community from the hospital, the facility may assist, with the request of the resident's representative, with provision of care assistance set up;
- Details regarding the transfer from the facility should be documented in the clinical record.
1. Review of Resident #11's medical record showed:
- admitted on [DATE] ;
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers.
2. Review of Resident #12's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers.
3. Review of Resident #38's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfer.
4. Review of Resident #44's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers.
5. Review of Resident #46's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfer.
6. Review of Resident #59's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers.
During an interview on 04/02/25 at 8:30 A.M., the Administrator said the facility had not been notifying the resident's representatives in writing of the resident's transfers to the hospital.
During an interview on 04/02/25 at 1:45 P.M., the Administrator said she would expect the transfer forms to be completed per the regulation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of their bed hold policy to the reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of their bed hold policy to the residents and/or their resident representatives at the time of transfer for four residents (Residents #11, #12, #38, and #46) out of 18 sampled residents and one resident (Resident #44) outside the sample. The facility census was 86.
Review of the facility policy titled, Bed Hold, dated 04/01/22, showed:
- It will be the policy of this facility to provide residents with bed hold policies upon admission to the facility and at the time of transfer (i.e. when transferring to hospital or going on therapeutic leave) in accordance with federal and state regulations;
- The initial bed hold policy should be provided to the resident/responsible party as soon after admission as possible when completing the admission packet to the facility. Should specify duration of the bed hold policy under the State Plan, if any, during which the resident is permitted to return and resume residence in the nursing facility. Non-Medicaid residents may be requested to pay for all bed hold days;
- The initial bed hold policy in the admission packet should be considered an example of how the bed hold policy works in the event it is required by the resident's conditions;
- The bed hold policy applies to all residents residing in the facility;
- The second bed hold policy should be provided at the time of the transfer and if applicable, given with in advance to the transfer;
- In emergency transfer situations, notice at the time of transfer refers to the provision of the resident's copy of the bed hold policy will be provided along with the other transfer paperwork to the hospital;
- Bed hold for days of absence in excess of the state's bed hold limit are considered non-covered services and the resident could use his/her own funds to pay for the bed hold if they desire;
- Residents that are non-Medicaid in payer source may be requested to pay for all days of bed hold;
- Residents are eligible for re-admission following hospitalization or therapeutic leave. per the facility's admission agreement. Private pay, Medicare or other residents not meeting the requirement of Medicaid bed hold: the facility will only reserve a bed for an absent resident if requested in writing by the resident or responsible party and applicable charges paid. In the event that a bed is not reserved, and the resident desires to re-occupy a room in the facility, the resident may be admitted to the next available bed.
1. Review of Resident #11's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers.
2. Review of Resident #12's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers.
3. Review of Resident #38's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer.
4. Review of Resident #44's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers.
5. Review of Resident #46's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer.
During an interview on 04/02/25 at 1:45 P.M., the Administrator said she would expect bed hold forms to be completed per the regulation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive intervention...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #78) 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 three sampled residents. The facility's census was 86.
Review of the facility's policy titled, Mental and Psychosocial Adjustment Services, dated 04/01/22, showed:
- It is the policy of the facility to ensure (based on the comprehensive assessment of a resident) that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or PTSD, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
- Residents who experience mental or psychosocial adjustment difficulty, or who have a history of trauma and/or PTSD require specialized care and services to meet their individual needs. The facility will ensure that an interdisciplinary team, which includes the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person-centered. Expressions or indications of distress, lack of improvement, or decline in resident's functioning should be documented in the resident's record and steps taken to determine the underlying cause of the negative outcome.
1. Review of Resident #78's medical record showed:
- admitted on [DATE];
- Diagnoses of PTSD, hemiplegia (paralysis of one side of the body) and hemiparesis following a cerebral infarction (stroke), bipolar disorder (a mental disorder that causes unusual shifts in mood), and mood disorder (any mental disorder with a disturbance of mood);
- Trauma Informed Care Assessment, dated 02/18/25, did not address the resident's PTSD triggers.
Review of the resident's Physician Order Sheet (POS), dated April 2025, showed:
- An order for mirtazapine (an antidepressant medication) 7.5 milligrams (mg) daily for mood disorder, dated 08/04/24;
- An order for sertraline (an antidepressant medication) 50 mg daily for mood disorder, dated 08/04/24.
Review of the resident's Preadmission Screening and Resident Review (PASRR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 08/23/24, showed:
- Resident with major depressive disorder (long-term loss of pleasure or interest in life), bipolar disorder, panic disorder, PTSD, and mood disorder;
- No behaviors documented.
Review of the resident's Care Plan, dated 08/14/24, showed:
- Did not identify PTSD as a problem;
- Did not address personalized triggers or interventions associated to the resident or triggers.
During an interview on 04/02/25 at 2:15 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) Coordinator said a diagnosis of PTSD should be addressed on the care plan with triggers listed.
During an interview on 04/02/25 at 3:15 P.M., the Administrator and DON said that they would expect PTSD and triggers to be addressed on the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide the nurse aides (NAs) an annual individual performance review or evaluation and failed to provide regular in-service education base...
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Based on interview and record review, the facility failed to provide the nurse aides (NAs) an annual individual performance review or evaluation and failed to provide regular in-service education based on these reviews for two certified nursing assistants (CNAs) (CNA A and CNA B). The facility census was 86.
Review of the Facility Assessment Tool, dated 04/10/24, showed:
- A facility must develop, implement, and maintain an effective training program for all new and existing staff;
- In-service training must address areas of weakness as determined in NA's performance reviews;
- In-service training may address the special needs of residents as determined by the facility staff.
1. Review of CNA A's employee file showed:
- A hire date of 09/15/08;
- No documentation of an annual performance review or evaluation;
- No documentation of annual in-service training based on the annual performance review or evaluation for the time frame from 09/15/23 through 09/15/24.
2. Review of CNA B's employee file showed:
- A hire date of 06/10/21;
- No documentation of an annual performance review or evaluation;
- No documentation of annual in-service training based on the annual performance review or evaluation for the time frame from 06/10/23 through 06/10/24.
During an interview on 04/02/25 at 3:05 P.M., the Administrator and Director of Nursing (DON) said they would expect CNAs receiving in-services to have at least 12 hours of training annually and for annual performance reviews to be done yearly. The DON and Assistant Director of Nursing (ADON) would be responsible for the annual performance reviews. There had been a lot of staff changes recently and the performance reviews were not done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for two residents (Residents #21 and #36) out of five sampled residents. The facility's census was 8...
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Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for two residents (Residents #21 and #36) out of five sampled residents. The facility's census was 86.
Review of the facility policy titled, Pharmacist Recommendations, dated 04/01/22, showed:
- It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines;
- The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart. An electronic medication regimen review will be performed within 72 hours of admission for newly admitted residents, or as soon as reasonably possible;
- The pharmacist must report any irregularities to the attending physician or Licensed Independent Practitioner (LIP) and the facility's Medical Director and Director of Nursing (DON), and these reports must be acted upon as soon as reasonably able, but prior to the following month's MRR; Irregularities include, but are not limited to, any drug that meets the criteria set forth for unnecessary drugs. Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician/LIP and the facility's Medical Director and DON and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. The attending physician/LIP must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician/LIP should document his/her rationale in the resident's medical record;
- Each resident's drug regimen must be free from unnecessary drugs;
- The facility, physician/LIP and/or pharmacist shall ensure that residents who have not used psychotropic (medications that affect the brain chemistry, mood, perception, and behavior) drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; Residents do not receive psychotropic drugs pursuant to an as needed (PRN) order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she should document their rationale in the resident's medical record and indicate the duration for the PRN order.
1. Review of Resident #21's medical record showed:
- admission date of 07/06/22;
- Diagnoses of anxiety (intense, excessive, and persistent worry and fear about everyday situations), major depressive disorder (a mental illness that causes a persistent low mood and loss of interest in activities), psychotic disorder with hallucinations due to known physiological condition (condition where a person experiences hallucinations and other psychotic symptoms like delusions or disorganized thinking), and schizophrenia (a disorder that affects a person's ability to think feel and behave clearly);
- An order for Depakote (an anti-seizure medication also used as a mood stabilizer) delayed release 125 milligram (mg) by mouth two times a day related to schizophrenia, dated 02/26/24;
- An order for Depakote delayed release 250 mg by mouth two times a day related to schizophrenia, dated 02/26/24;
- The physician did not attempt GDRs for the Depakote 125 mg and the 250 mg doses;
- The physician did not document any contraindications of medication adjustments for the Depakote 125 mg or 250 mg doses.
2. Review of Resident #36's medical record showed:
- admission date of 06/29/23;
- Diagnoses of Alzheimer's Disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), anxiety disorder, major depressive disorder, auditory hallucinations, and visual hallucinations;
- An order for olanzapine (an antipsychotic (medication used to treat psychosis) 2.5 mg twice a day for delusions, dated 01/01/24;
- The physician did not attempt GDRs for the olanzapine 2.5 mg dose
- The physician did not document any contraindications of medication adjustments for the olanzapine 2.5 mg.
During an interview on 04/02/25 at 9:33 A.M., the Assistant Director of Nursing (ADON) said they did not do GDRs.
During an interview on 04/02/25 at 1:30 P.M., the Administrator said she would expect GDRs to be completed per the regulation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
Based on interview and observation, the facility failed to ensure bedtime snacks had been offered to all residents at bedtime. This had the potential to affect all residents in the facility. The facil...
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Based on interview and observation, the facility failed to ensure bedtime snacks had been offered to all residents at bedtime. This had the potential to affect all residents in the facility. The facility census was 86.
Review of the facility policy titled, Nutrition and Hydration Assistance, dated 04/01/22, showed:
- Additional sources of nourishment should/may include provision of snacks;
- Staff will make provision for appropriate snacks as requested or ordered by the physician.
Review of the facility policy titled, Provide Diet to Meets Needs of Each Resident, dated 04/01/22, showed:
- The facility would provide the services of a Registered Dietitian Nutritionalist or designee to participate in the interdisciplinary care planning team and assure that the nutritional needs of individuals living in the facility are met.
Review of the meal times, as provided by the facility, showed breakfast was served at 7:30 A.M., lunch was served at 11:30 A.M., and dinner was served at 4:30 P.M. with a 16 hour gap between each dinner and breakfast.
During group interview on 03/31/25 at 1:20 P.M., Residents #1, #17, #33, and #35 said snacks were kept at the nurse's station at night. If you were not able to physically go up and ask for a snack, then you did not get one. Staff did not round on the residents to see if they wanted a snack.
Observation on 03/31/25 from 10:15 P.M. through 11:30 P.M., showed:
- A snack cart kept by the nurse's station;
- The only residents that received snacks were the residents who physically came to the nurse's station to ask for one;
- Staff did not round to pass or offer the residents a snack.
During an interview on 04/02/25 at 11:30 A.M., the Dietary Manager said snacks were left each night behind the nurse's station for anyone who wanted them, and did not think each resident was supposed to be offered one. He/She did not think staff rounded on each resident to offer them a snack.
During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect each resident to be offered a snack at night.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. The f...
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Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. The facility failed to ensure that foods were kept covered while waiting to be served and had policies and procedures in place for food brought in from outside the facility. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 86.
Review of the facility policy titled,Food Delivery and Storage, dated 10/01/23, showed:
- It will be the policy of this facility that foods shall be received and stored in a manner that complies with safe food handling practices;
- Dietary/Food Services, or other designated staff, will maintain clean food storage areas at all times;
- Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system;
- All foods stored in the refrigerator or freezer will be covered, labeled, and dated.
1. Observation on 03/30/25 at 10:30 A.M., of the kitchen showed:
- Pancakes, hashbrowns, and an open metal container of a brown substance in the freezer with no label or date on the contents;
- Opened wrapped margarine, wrapped cut up onion, four metal pans not dated with two of them open and unlabeled, and two trays of red jello uncovered and not dated in the refrigerator;
- Three unlabeled and undated tubs with cereal sat on cart outside the freezer;
- Inside of the oven with brown/black debris and buildup with pieces of aluminum foil on the floor of the oven;
- Stove top with all six burners with black/ brown debris and buildup;
- One #10 can of beans and two #10 cans of sauerkraut commercial cans unlabeled;
- A bag of sugar in a plastic tub with no date or label.
2. Observation on 03/30/25 from 11:30 A.M. - 12:28 P.M., showed:
- Drink cart containing lunch drinks for the residents uncovered in the dining room;
- Three different unknown residents self-poured coffee from the coffee container in the dining room with one of those residents coughing before pouring his/her drink;
- One unknown resident in a wheelchair pushed him/herself to a cart with an orange drink picture on it in the dining room, poured his/her old drink out through the kitchen window with some of the liquid spilling on the trays, picked up the picture with the right hand, poured orange drink into the old container, and put the orange picture back on the cart.
3. Observation on 03/31/25 at 10:45 P.M., showed:
- An ice machine behind the nurse's station in a room;
- The outside of the ice machine was covered with brown and white substance;
- An unknown resident walked into the room, grabbed the ice scoop with his/her bare hand, opened the ice machine door, scooped ice into cup in his/her left hand, and placed the scoop back in the container on the refrigerator located next to the ice machine.
4. Observation on 04/01/25 at 5:02 P.M., showed:
- A kitchen cart in the dining room with four out of four trays of uncovered beverages.
5. Observation on 04/02/25 at 10:36 A.M., of the kitchen showed:
- Pancakes, hashbrowns, and an open metal container of a brown substance in the freezer with no label or date on contents;
- Opened wrapped margarine, wrapped cut up onion, four metal pans not dated with two of them open and unlabeled, and two trays of red jello uncovered and not dated in the refrigerator;
- Three unlabeled and undated tubs with cereal sat on a cart outside the freezer;
- Inside of the oven with brown/black debris and buildup with pieces of aluminum foil on the floor of oven;
-Stove top with all six burners with black/ brown debris and buildup;
- One #10 can of beans and two #10 cans of sauerkraut commercial cans unlabeled;
- A bag of sugar in a plastic tub with no date or label;
- One tub labeled powdered milk with an undated bag of salt inside;
- One bag of white cream baking chips opened and undated.
During an interview on 04/02/25 at 10:50 A.M., the Dietary Manager (DM) said he/she would expect everything in the refrigerator, freezer, and dry storage to be labeled and dated appropriately. He/ She would expect the kitchen equipment to be working correctly and cleaned after use. The stove top and oven could use a better cleaning and drinks should be covered when leaving the kitchen. The coffee was self-serve but did not know of anything for infection control for it but would look into it.
During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect food products to be labeled and stored appropriately, food and drinks to be covered when exiting the kitchen to go to the resident room for resident use, and for kitchen equipment to be clean and working correctly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain or implement a policy regarding the acceptance, usage, and storage of foods brought into the facility for residents ...
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Based on observation, interview, and record review, the facility failed to maintain or implement a policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by food delivery services, family, and/or other visitors, to ensure the food's safe and sanitary handling, storage, and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 86.
Review of the facility form titled, Resident Responsibilities and Rules, Appendix 4, undated, showed:
- Food may be brought into our facility;
- It must be kept in airtight containers;
- Because of diet restrictions, nursing staff should be made aware of any food brought into the facility;
- Should food need to be monitored, it will be kept in a designated room;
- The policy did not address how facility staff will assist the resident in accessing and consuming the food brought in by visitors in a way that either separates or easily distinguishes from the facility food.
Observation on 03/31/25 at 10:45 P.M., a refrigerator located next to ice machine behind the nurse's station had dated resident snacks provided by the facility and several unmarked and undated food items in multiple types of bags and containers in it not provided by the facility.
During an interview on 03/31/25 at 10:30 P.M., [NAME] G said snacks were kept behind the nurse's station and residents had access to it. All items in the refrigerator should be labeled with a date and name.
During an interview on 04/02/25 at 2:30 P.M., the Dietary Manager (DM) said he/she did not know if the facility had any policies about outside food brought in for the residents. He/She had not had any food brought into the kitchen that was a resident's property.
During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect to have a policy regarding the use and storage of foods brought to residents by family members or other visitors to ensure safe and sanitary storage, handling, and consumption.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect ...
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Based on observations, interviews, and record review, the facility failed to maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect all residents. The facility census was 86.
The facility did not provide a policy for equipment maintenance.
Review of the following invoices showed:
- On 12/16/24, an invoice for a laundry washer was serviced but no details of actions taken;
- On 12/30/24, an invoice for a laundry washer was serviced with a valve and hose replaced.
Observation on 04/02/25 at 9:40 A.M. of the laundry room, showed:
- Three commercial laundry washing machines;
- Two of the machines were covered in dust and debris and not in use;
- The third machine was running a load of laundry. On top of the third machine was a plastic cup marked with a black line which indicated the fill line for bleach to pour into each load of laundry.
During an interview on 04/02/25 at 9:40 A.M., Laundry Aide (LA) K said he/she had been a laundry employee for over a year and in that time, only one of the three washing machines had worked. The one washer that did work had broken down several times and each time the residents had to go two days or more without clothes getting washed. The working washer broke down every couple of months, and was probably due any time. LA K said they did at least 50 loads of laundry a day, which took it's toll on the one machine. At this moment, the one working machine did not get any hot water for some reason, and the detergent dispensing equipment was not working as well. LA K said for the time being, they were manually adding detergent and bleach to each load. When the only washer did break down, arrangements were made to take the laundry to a laundry mat. Arranging to get all the laundry to and from the laundry mat was complicated and delayed the process time significantly. LA K said the facility administration/company owners had said there was a quote to get a washer a while back, but he/she did not think it would happen.
During an interview on 04/02/25 at 10:10 A.M., the Maintenance Director (MD) said there was a quote for a commercial laundry washing machine, but did not know where the company was in the process of actually getting one. He/She was aware of the hot water problem, and hoped the latest filter replacement would help get the hot water to the laundry
During an interview on 04/02/25 at 2:00 P.M., the Administrator said the backup plan for when the laundry machine went out would be to go to the laundromat. She would expect the laundry equipment to be in proper working conditions and function appropriately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of the overbed light fixtures for residents...
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Based on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of the overbed light fixtures for residents in three rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 86.
The facility did not provide a policy regarding storing items on the overbed light fixtures.
1. Observation on 03/03/25 at 2:39 P.M., of Room B 5-1 showed a large picture in a wooden frame on the light above the resident's bed.
2. Observation on 03/31/25 at 11:09 P.M., of Room C 8-2 showed three medium sized stuffed animals, two medium glass figurines, and two small plastic animals on the light fixture above the bed on the left side of the room.
3. Observation on 04/01/25 at 1:00 P.M., of Room C 10-2 showed two large stuffed animals and three medium sized stuffed animals on the light fixture above the bed on the right side.
4. Observation on 04/01/25 at 4:30 P.M., of Room A 6-1 showed one medium stuffed animal and one boxed figurine resting on the light fixture above the bed.
During an interview on 04/02/25 at 1:15 P.M., the Maintenance Director said he/she could purchase shelves for the residents' personal belongings. The light fixtures above the bed should be free of clutter for safety reasons.
During an interview on 04/02/25 at 1:45 P.M., the Administrator said she would expect light fixtures to be free from items due to a possible fire hazard.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide (NA) in-service education per year. This affected two Certified Nurse Assistants (CNAs) (CNA A ...
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Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide (NA) in-service education per year. This affected two Certified Nurse Assistants (CNAs) (CNA A and CNA B) out of two sampled CNAs. The facility's census was 86.
The facility did not provide a policy regarding annual NA education.
1. Review of CNA A's employee file showed:
- A hire date of 09/15/08;
- A total of 2 hours 50 minutes of annual in-service training completed for the time frame of September 2023 through September 2024;
- The facility failed to provide at least 12 hours of in-service education for September 2023 through September 2024.
2. Review of CNA B's employee file showed:
- A hire date of 06/10/21;
- A total of 5 hours 45 minutes of annual in-service training for June 2023 through June 2024;
- The facility failed to provide at least 12 hours of in-service education for June 2023 through June 2024.
During an interview on 04/02/25 at 3:05 P.M., the Administrator and Director of Nursing (DON) said they would expect CNAs to receive at least 12 hours of training annually.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This deficiency had the potentia...
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Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This deficiency had the potential to affect all residents. The facility census was 86.
The facility did not provide a RN coverage policy.
Review of the facility's Facility Assessment Tool, dated 4/10/24, showed:
- The facility required five licensed nurses providing direct care for day shift, which included at least one RN for the day shift.
Review of the Nursing Schedules and the Daily Nursing Staffing Sheets for 01/01/25 - 03/31/25, showed:
- No RN coverage for eight consecutive hours on 01/06/25, 01/23/25, 01/24/25, 01/27/25, 01/30/25, 01/31/25, 02/03/25, 02/06/25, and 02/07/25;
- No RN coverage for eight consecutive worked for nine days out of 90 days.
During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect the facility to have an RN working eight consecutive hours daily seven days a week.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kit...
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Based on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 86.
Review of the facility policy titled, Qualified Dietary Staff, dated 10/01/23, showed:
-The dietary/ food services department is staffed by dietary/ food and nutrition services personnel to meet the needs of the residents and the skilled Dietitian will help oversee the dietary/ food and nutrition services in the facility;
-The Dietitian or nutrition professional may be full time or part time consultant or an employee, depending on the current requirements of the facility;
-The qualifications of the Dietitian will include a bachelor's degree from a regionally accredited college with successful completion of a nationally accredited program in nutrition or dietetics, completion of at least 900 hours of dietetics practice supervised by a registered dietitian or nutritional professional, or certification as a dietitian or nutritional professional by the state services are being performed;
-If a dietitian is not employed full time, then a director of food service management will be designated and will be a certified dietary manager, certified food service manager, be nationally certified in food service management and safety, or have an associate's degree or higher in food service management and meet any state requirements and receive frequently scheduled consultations from a qualified dietitian or nutritional professional.
Review of the Dietary Manager (DM) showed he/ she received a certificate of training for completing the food handler essentials course, dated 12/13/24, from StateFoodSafety. Review of the facility's current employee list, undated, showed a hire date of 09/30/24 for the Dietary Manager (DM).
During an interview on 03/30/25 at 11:30 A.M., the DM said he/she started the role of DM in November of 2024. The previous facility company had worked it out that they would pay for him/her to become certified but then have not done anything yet and do not know if they will now that the facility had a new company in charge. If the facility would help him/her get certified, then he/she would have no problem taking the classes as he/she was more than willing and wanting to become certified.
During an interview on 03/31/25 at 5:00 P.M., the Registered Dietician (RD) said she signed a contract to start yesterday 03/30/25 as the RD. She had worked here in the past and does not think they have had a RD for months. She talked to the DM and said he/she is not certified yet but hopeful that the facility would be helping that problem soon.
During an interview on 04/02/25 at 3:05 P.M., the Administrator would expect the DM to be certified and qualified. The facility had not had an RD since august 2024.
MINOR
(C)
Minor Issue - procedural, no safety impact
Resident Rights
(Tag F0550)
Minor procedural issue · This affected most or all residents
Based on observation and interview, the facility failed to promote resident independence and dignity while dining when staff served the noon meal on disposable dishware. The facility census was 86.
Re...
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Based on observation and interview, the facility failed to promote resident independence and dignity while dining when staff served the noon meal on disposable dishware. The facility census was 86.
Review of the facility policy titled, Resident Rights, Dignity and Visitation Rights, dated 04/01/22, showed:
- It will be the policy of this facility that employees shall treat residents with kindness, respect, and dignity. The facility promotes the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. The facility will ensure that the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability;
- The facility will make effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity; providing care that is comfortable and consistent with his/her normal life habits, observing resident's choices whenever able;
- The facility will promote care for residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his/her individuality, preferences, activities, pursuits, goals, and desires.
Review of the facility policy titled, Dishes and Infection Control Practices, dated 10/01/23, showed:
- Routine use of disposables for residents in isolation/infection precautions is not recommended unless directed by the Infection Preventionist (IP). Residents requiring isolation precautions may utilize disposable products at the discretion of the facility IP and administration;
- If adequate resources for cleaning utensils and dishes are not available, then disposable products may be used.
Observation on 03/30/25 at 11:45 A.M., showed:
- All residents served lunch from the kitchen on disposable plates, cups, and bowls.
During an interview on 03/30/25 at 11:33 A.M., Day [NAME] I said the kitchen was shorter staffed on the weekends and served food on paper plates. There was not enough time to cook, clean, and serve with just two staff.
During an interview on 03/30/25 at 11:42 A.M., Resident #24 said meals were often served on paper plates.
During an interview on 03/30/25 at 3:03 P.M., Resident # 71 said staff served food on styrofoam plates and cups a lot instead of using real dinnerware.
During an interview on 03/30/25 at 3:07 P.M., Resident #21 said they always used disposable utensils and plates instead of real dinnerware.
During an interview on 03/31/25 at 10:15 P.M., Day [NAME] G said he/she thought the paper products were used more for convenience than not being able to do dishes. Multiple residents had complained about the food being served on paper plates.
During an interview on 04/02/25 at 11:35 A.M., the Dietary Manager (DM) said he/she did not like when staff served food on paper plates. Staff were not supposed to serve food on paper plates but sometimes did one meal a day on the weekends. There were enough dishes where staff did not have to use paper products.
During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect meals to be served in a way that promotes and maintains dignity and respect for the residents.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0679
(Tag F0679)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an on-going program of activities designed to...
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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 an on-going program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This practice affected five residents (Residents #13, #21, #22, #24, and #31) out of 18 sampled residents and could potentially affect all residents. The facility census was 86.
Review of the facility policy titled, Activities, dated 04/01/22, showed:
- It will be the policy of this facility to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an on-going program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community;
- The facility shall provide an on-going person-centered activities program that incorporates the resident's interests, hobbies, and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial wellbeing and independence;
- The facility shall create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning);
- The facility shall provide meaningful activities that reflect a person's interests and lifestyle, are enjoyable to the person, help the person to feel useful, and provide a sense of belonging;
- The program will be based on the resident's comprehensive assessment and person-centered care plan, and meet the resident's interests and preferences, and support his/her physical, mental, and psychosocial well-being;
- Activities can occur at any time, are not limited to formal activities being provided by recreation staff, and can include activities provided by other facility staff, volunteers, visitors, residents, and family members;
- Programs should reflect a resident-centered perspective including programming that takes into consideration physical function, behavioral changes, cognitive function and historical recreation preferences: activity preferences; one-to-one programs, independent activities/in-room activities, etc., group programming, community based, person-centered, gender, cultural, religious/spiritual, individual preferences, and continuation of life roles (former occupation, personal preferences, hobbies, etc.);
- The facility will develop a monthly schedule of activities which will be accessible to residents or the facility will provide for in room/self-directed activities as determined by the activity assessment;
- The facility will honor the resident preference to be independently capable of pursuing their own activities without intervention from the facility. This information will be noted in the assessment and identified in the person-centered care plan;
-The facility will support the resident's preferences to remain involved in the community including interactions such as: assisting the resident to maintain his/her ability to independently shop, attend the community theater, local concerts, library. and participate in community groups.
Review of the March 2025 Activities Calendar showed:
- Two activities per day;
- The morning showed coffee with either music, communion, coloring, or currents events;
- The afternoon showed games such as bingo, charades, bowling, Deal or No Deal, and Family Feud or an activity of an ice cream social, [NAME] Krispie treats, and resident council meeting;
- On Mondays and Wednesdays, there was time listed as 1:1.
1. Review of Resident #13's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 09/14/24, showed:
- Very important to participate in activities he/she likes.
During an interview on 03/30/25 at 2:39 P.M., Resident #13 said the facility removed the Activities Room. The facility used to have an Activities Room, but it was taken away and the staff expect everything to be held in the dining room. They had a coffee hour in the morning, but they were no longer provide the different creamers. He/She had to purchase his/her own creamer and donated it to the other residents who liked to use it. They didn't normally do anything during the coffee hour like the music or current event listed. It was just coffee in the dining area if residents wanted it. He/She said it wasn't an activity. The calendar listed games in the afternoon, but that was it and nothing else was available for them to do and nothing that interestd him/her. The activities person did not do 1:1 activities with him/her and did nothing for the residents.
2. Review of Resident #21's annual MDS, dated [DATE], showed:
- The preferences for routine and activities section not completed.
During an interview on 03/30/25 at 3:07 P.M., Resident #21 said the facility did not do activities and if they did, he/she did not know what they were. He/She wished they would do activities so it would give him/her something to do, because watching TV got old. He/She did not know who the activities person was and had never had anyone do any 1:1 activities with him/her.
3. Review of Resident #22's annual MDS, dated [DATE], showed:
- Very important to participate in activities he/she likes.
During an interview on 03/30/25 at 12:04 P.M., Resident #22 said activities were non-existent. The facility provided a calendar, but half the time, they didn't do anything that was listed on it. The residents used to have an Activities Room but it was taken away. The residents were told any activities would have to be in the dining room and then that was when the staff quit doing them.
4. Review of Resident #24's significant change MDS, dated [DATE], showed:
- The preferences for routine and activities section not completed.
During an interview on 03/30/25 at 1:16 P.M., Resident #24 said the facility did not have activities he/she could do. He/She spent most days watching TV in his/her room because there was nothing else to do.
During an interview on 03/31/25 at 1:16 P.M., Resident #24 said the Activity Director had never done any sort of 1:1 time that he/she could recall.
5. Review of Resident #31's admission MDS, dated [DATE], showed:
- Very important to participate in activities he/she likes.
During an interview on 03/30/25 11:31 A.M., Resident # 31 said they provided no activities that interested him/her. Half the time what they had listed on the calendar, they didn't even do. The closest thing to an activity he/she had to do was taking a smoke break.
During an interview on 03/30/25 at 1:28 P.M. the Activities Director said for residents that needed accommodations, he/she used things like music, movies, or audio books, and tried to do 1:1 time with them to hang out and talk with them for their activities.
During an interview on 04/02/25 at 1:54 P.M., the Administrator said she would expect activities to be provided that met the physical, mental, and psychosocial well-being of the residents.
Feb 2025
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide consistent resident care for activities of da...
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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 consistent resident care for activities of daily living (ADLs) when the residents went an extended amount of time without showers for three residents (Resident #1, #2, and #3) out of 6 sampled residents. The facility's census was 92.
The facility did not provide a policy regarding showers.
1. Review of Resident #1's medical record showed:
- An admission date of 07/26/24;
- Diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation (disease that makes breathing difficult), type 2 diabetes mellitus with hyperglycemia (trouble controlling blood sugar), need for assistance with personal care, conversion disorder with seizures or convulsions (a condition where psychological distress manifests as physical symptoms, including seizures), and Parkinson's disease without dyskinesia (Parkinson's without involuntary movements).
Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 01/01/25, showed:
- Cognitive status intact;
- Partial or moderate assistance for dressing;
- Partial or moderate assistance for toileting;
- Supervision or touching assistance for personal hygiene;
- Partial or moderate assistance for bathing.
Review of the resident's care plan, dated 02/04/25, showed:
- The resident with an ADL self-care performance deficit due to decreased mobility, poor endurance, and chronic health conditions.
Observation on 02/06/25 at 10:25 A.M. showed the resident lay in bed with disheveled, unkempt hair, sticking out and falling out of a pony tail.
During an interview on 02/06/25 at 10:25 A.M., Resident #1 said he/she will go weeks without a shower. He/she said staff will tell him/her they didn't have the time or enough staff to complete his/her shower. Resident #1 said staff will mark the shower sheets as refused when he/she did not refuse the shower. Staff will promise him/her they will complete the shower the next day, but will still not have time, which causes him/her to go weeks without getting to shower.
Review of the facility shower schedule showed Resident #1's shower days to be Wednesday and Saturday.
Review of the resident's shower sheets for December 2024 through January 2025, showed:
- In December 2024, 2 showers documented out of 8 opportunities, a total of 6 opportunities for showers missed;
- In January 2025, 3 showers documented out of 9 opportunities, a total of 6 opportunities for showers missed.
2. Review of Resident #2's medical record showed:
- admission date 04/15/24;
- Diagnoses of type 2 diabetes mellitus with diabetic neuropathy (trouble controlling blood sugar), unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (trouble breathing), COPD, unspecified, chronic kidney disease, stage 3b (kidneys not working properly), and acquired absence of left leg above knee (lower leg removed).
Review of the resident's quarterly MDS, dated [DATE], showed:
- Cognitive status intact;
- Dependent on staff for dressing;
- Dependent on staff for toileting;
- Dependent on staff for personal hygiene;
- Dependent on staff for bathing.
Observation on 02/06/25 at 10:15 A.M. showed the resident with disheveled, unkempt and greasy hair.
During an interview on 02/06/25 at 10:15 A.M., Resident # 2 said he/she will go weeks without a shower and would like to be showered more often. He/she said staff will not clean him/her which has caused him/her to be very smelly around the private area and has caused issues with yeast and sores on his/her body. Resident #2 said it is embarrassing and he/she is self conscious about his/her body odor and unkempt appearance.
Review of the facility shower schedule showed Resident #2's shower days to be Monday and Thursday.
Review of the resident's shower sheets for December 2024 through January 2025, showed;
- In December 2024, 1 shower documented out of 7 opportunities, a total of 6 opportunities for showers missed;
- In January 2025, 1 shower documented out of 7 opportunities, a total of 6 opportunities for showers missed.
3. Review of Resident #3's medical record showed:
- admission date 02/12/01;
- Diagnoses of cerebral palsy (congenital disorder of movement, muscle tone, and posture), pseudobulbar affect (inappropriate laughing or crying due to a nervous system disorder), dysphagia, oropharyngeal phase (difficulty swallowing food or liquid), schizophrenia (a disorder that affects a person ability to think, feel, and behave clearly), unspecified, and moderate intellectual disabilities (developmental delay that affects a person's ability to understand and use language, communicate and learn).
Review of the resident's quarterly MDS, dated [DATE], showed:
- Cognitive status moderately impaired;
- Dependent on staff for dressing;
- Dependent on staff for toileting;
- Dependent on staff for personal hygiene;
- Dependent on staff for bathing.
Review of the resident's care plan, dated 02/04/25, showed:
- The resident to have an ADL self-care performance deficit related to cerebral Palsy.
Observation on 02/06/25 at 10:15 A.M. of Resident #3 showed:
- Disheveled hair;
- Hair on upper lip;
- Food on front of shirt and in lap;
- Faint smell of urine.
Review of the facility shower schedule showed Resident #3's shower days to be Wednesday and Saturday.
Review of the resident's shower sheets for December 2024 through January 2025, showed;
- In December 2024, 4 showers documented out of 8 opportunities, a total of 4 opportunities for showers missed;
- In January 2025, 5 showers documented out of 9 opportunities, a total of 4 opportunities for showers missed.
During an interview on 02/06/25 at 1:51 P.M., the Assistant Director of Nursing (ADON) said the aides that work the halls should be completing the resident showers following the shower schedule. They should fill out a shower sheet every time. Staff should write refused on them if the resident does not want to have a shower. The ADON said if the resident can shower themselves, the staff should still be completing a shower sheet. The ADON said they have had issues with some staff not completing them. He/she said they have been trying to weed out the bad seeds and feels like staff have been doing better about completing them in the last couple of weeks.
During an interview on 02/06/24 at 4:09 P.M., Certified Nurse Aide (CNA) A and CNA B said there is a binder at the front desk that tells who staff are supposed to shower for the day. CNA A and B both said they complete a shower sheet each time if the resident refuses a shower or if the resident completes the shower by himself/herself. They both said if a resident showers independently, they stand by in case they need something. Both aides said they will sign the shower sheet, the resident will sign the shower sheet and the DON will take the shower sheet to upload in the chart. Both aides denied they have ever marked refused if they do not actually refuse to take a shower and always complete their shower sheets.
During an interview on 02/06/25 at 4:15 P.M., the Interim Director of Nursing (DON) said there's a basket at the nurse's station and the aides put the completed shower sheets in and she will file them to be scanned in the chart. He/she said sometimes the CNAs in the evening will say they are too busy to get them completed. He/she said some aides are good about completing shower sheets and others are not. He/she said the evening shift struggles to get showers completed. He/she said there is an alert in the electronic records system that will pop up to say when a resident hasn't had a shower in seven days. He/she says when those alerts pop up, he/she will complete a shower sheet and take it to the nurse to tell them the resident must have a shower that day. He/she said there are residents that will refuse showers. He/she said they will verify when the residents refuse the showers.
Complaint #MO00249132
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
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, facility staff failed to properly maintain the temperature of hot food at or above 120 Degrees Fahrenheit (°F) for 12 residents (Residents #1, #...
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Based on observation, interview, and record review, facility staff failed to properly maintain the temperature of hot food at or above 120 Degrees Fahrenheit (°F) for 12 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12), out of 12 sampled residents, at the time of meal service and failed to implement a system to monitor food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents receiving meal trays. The facility's census was 94.
Review of the Missouri Food Code for the Food Establishments of the State of Missouri, provided by the facility and dated June 3, 2013, showed:
- Refrigerated, potentially hazardous food shall be at a temperature of 41 degrees Fahrenheit or below when received;
- Potentially hazardous food that is cooked to a temperature and for a time specified under section 3-4.11-3.401.13 and received hot shall be at a temperature of 135 degrees Fahrenheit.
The facility did not provide a policy related to food service tray temperatures or a system of monitoring food tray temperatures at service time.
The facility did not provide temperature logs of food served on hall trays.
1. Review of the facility's Resident Council Meeting Minutes, dated 12/11/24, showed the food has not been appetizing lately and served cold.
During an interview on 12/13/24 at 11:15 A.M., Resident #6 said the food is terrible and it's cold.
During an interview on 12/13/24 at 12:28 P.M., the Dietary Manager (DM) said he/she has a heated food service cart, however it is not used for the daily meals. The heated cart is only used for meal service when food needs to be held for an extended period of time. Daily meals are delivered on open tray carts. Dietary staff plate the food and cover with an insulated lid, then slide on to the cart. Staff then push the carts to the appropriate halls. The DM said he/she sometimes had issues with food temperatures because staff don't pass the trays timely.
Observation on 12/13/24 of the lunch hall tray pass showed:
- At 12:28 P.M., dietary staff began plating the resident lunch meal. Each plate was covered and placed on a tray in a slot in a metal cart and wheeled out of the dining area;
- At 12:38 P.M., the open, uncovered hall tray cart was pushed to C hall;
- At 12:42 P.M., staff began pushing the cart down C hall and delivering trays;
- At 12:56 P.M., staff finished delivering trays to the residents on C hall.
Observation on 12/13/24 at 12:58 P.M. of a lunch meal from an unserved tray on the hall tray cart showed:
- Salisbury steak with a temperature of 105.2 °F;
- Broccoli with a temperature of 100.5 degrees °F;
- Potatoes with a temperature of 121.1 degrees °F;
- Mandarin oranges with a temperature of 64.2°F;
- Mighty Shake (a supplement with extra calories and protein) with a temperature of 58.6 °F.
Observation on 12/13/24 at 1:01 P.M. of a test tray, requested by the surveyor, showed: - The plate, delivered by the DM, sat on a plate warmer and was covered with a lid;
- Salisbury steak with a temperature of 158.5 °F;
- Broccoli with a temperature of 158.8 °F;
- Potatoes with a temperature of 159.9 °F;
- Mandarin oranges with a temperature of 70.2 °F.
During an interview on 12/13/24 at 1:01 P.M., the DM said he does not have enough plate warmers to go around, but he has told the Administrator he would like to have some.
Observation on 12/13/24 of the evening meal hall tray pass showed:
- At 6:35 P.M., dietary staff placed residents' dinner trays with plates covered on an open, uncovered hall tray cart;
- At 6:45 P.M., staff began to pass trays on C hall;
- At 6:56 P.M., staff finished passing trays on C hall.
Observation on 12/13/24 at 6:56 P.M. of a dinner meal test tray showed:
- Fish with a temperature of 136 °F;
- Tater tots with a temperature of 128.5 °F;
- Salad with a temperature of 64.9 °F;
- Cake with a temperature of 67.3 °F.
Observation on 12/13/24 at 6:58 P.M. of a dinner meal from an unserved tray on the hall tray cart showed:
- Fish with a temperature of 99.2 °F;
- Tater tots with a temperature of 97.2 °F;
- Salad with a temperature of 76.5 °F;
- Cake with a temperature of 69.8 °F.
During an interview on 12/13/24 at 7:25 P.M., the DM said he/she does not have a policy for food service. He uses the Missouri Food Code. The temperatures for cold food should be 41 °F or below and the hot food should be above 135 °F. He/She didn't realize temperature logs weren't being completed since 12/01/24 until just now. He/She would expect the food served to the residents to be at proper temperatures when they receive it. The cold foods should be served cold and the hot foods should be served hot.
During an interview on 12/13/24 at 7:45 P.M., the Administrator said she does not have a food service policy. The facility uses the Missouri Food Code instead. She has been working very hard to get the dietary issues corrected. She would expect food to be palatable and served at safe temperatures.
Complaint #MO00245733 & MO00246557
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #1) out of eleven sampled residents when Resident #1 did not receive five doses of his/her seizure medication. The facility census was 87.
Review of the facility's policy titled, Medication Administration, dated 09/01/22, showed:
- Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards, in a manner to prevent contamination or infection;
- Correct any discrepancies and report to the nurse manager;
- The policy did not address what to do if the medication was not available.
1. Review of Resident #1's medical record showed:
- admission date of 06/19/24;
- Diagnoses of epilepsy (a neurological condition characterized by recurrent seizures due to abnormal electrical activity in the brain), history of malignant neoplasm of the brain (brain cancer), diabetes mellitus (elevated blood sugar) and generalized anxiety disorder (GAD - persistent worry and fear about everyday situations);
- August 2024 Physician Order Sheet (POS) showed an order for cenobamate (a seizure medication) 150 milligram (mg) by mouth at bedtime for seizures, dated 06/19/24;
- Nurses' Note, dated 08/24/24 at 9:34 A.M., resident in a full body seizure and did not respond to verbal stimuli. Resident continued to have a seizure for four minutes. Resident awakened but was lethargic. A Certified Medication Technician (CMT) reported the resident hadn't received all his/her seizure medication. The resident had been out of his/her night time seizure medication for several days. The pharmacy was called about the missing night time seizure medication and said the medication had been delivered to the facility on [DATE]. The missing night time medication was found on the nurse medication cart instead of the CMT cart. The physician was notified and received an order to give a one time dose of cenobamate 150 mg now and to resume the cenobamate 150 mg night time dose on 08/24/24. The resident received a small scratch to the left hand.
Review of the resident's Medication Administration Record (MAR), dated 08/01/24 through 08/31/24, showed:
- Cenobamate 150 mg not administered on 08/19/24, 08/20/24, 08/21/24, 08/22/24 and 08/23/24;
- Five missed doses out of 31 doses.
Review of the Medication Error report, dated 08/24/24 at 10:14 A.M., showed Resident #1 had a four minute seizure in his/her room. The CMT informed the nurse the resident had been out of his/her bed time dose of cenobamate for multiple days. The pharmacy was called for a STAT (immediate) refill of the resident's cenobamate. The pharmacy said the prescription was delivered to the facility on [DATE]. Upon further investigation, Resident #1's cenobamate was found in the nurses's medication cart and not the CMT medication cart.
Review of Resident #1's Controlled Drug Receipt/Record/Disposition Form showed Registered Nurse (RN)/Assistant Director of Nursing (ADON) received 14 tablets of cenobamate on 08/19/24, from the pharmacy.
During an interview on 10/08/24 at 10:30 A.M., the ADON said the facility had medication carts for the nurses and medication carts for the CMTs to administer medications from. She checked in Resident #1's refill of cenobamate medication on 08/19/24, and placed it in the nurse's medication cart by mistake.
During an interview on 10/08/24 at 12:40 P.M., RN A said it was the facility's policy for CMTs to notify the nurses when a medication was unavailable to administer to a resident. The nurse would call the pharmacy for a STAT fill of a resident's medication.
During an interview on 10/08/24 at 1:30 P.M., the Director of Nursing (DON) and the ADON/RN E said they would expect a CMT to immediately notify the nurse of any unavailable medication or missed doses, so the nurse could immediately initiate the refill process.
During an interview on 10/08/24 at 1:35 P.M., the Administrator said she would expect medications to be available and administered according to the physician orders.
During a telephone interview on 10/15/24 at 3:03 P.M., the Physician said he/she would expect residents to receive their medications as ordered. The facility notified him/her of Resident #1's seizure on 08/24/24, along with the missed cenobamate doses. Resident #1 did not have another seizure after his/her cenobamate medication was restarted on 08/24/24, so the resident's seizure could have been induced by the missed doses of the cenobamate medication.
During an interview on 10/30/24 at 3:25 P.M., the Pharmacy Manager said Resident #1's cenobamate 150 mg per mouth at 8:00 P.M., was sent out to the facility on [DATE], with a count of 14 tablets. Licensed Practical Nurse (LPN) D signed for the medication on 08/16/24. On 08/19/24, 14 tablets of the same medication was sent to the facility and RN E signed for the medications at the facility. On 08/28/24, 14 tablets of the same medication was sent to the facility and LPN F signed for the medication at the facility.
During an interview on 10/30/24 at 3:45 P.M., RN J said he/she was not made aware of Resident #1's missing prescription of cenobamate 150 mg per mouth at 8:00 P.M., until he/she questioned a CMT about the the resident missing several doses of his/her seizure medication while the resident was actively having a seizure on 08/24/24. The night nurse, RN E, signed off on the medication and placed the medication in the nurse cart instead of the CMT cart. He/She said two CMTs were working during that time, CMT G and CMT H, and they both notified the night nurses, RN E and LPN I, about the medication not being available. The night nurses did not pass along any information to any day shift nurses, including himself/herself that the medication wasn't available. The day shift CMTs were not aware of the missing medication because it was scheduled for 8:00 P.M. He/She never had an issue with getting any medications, including routine medications, from the pharmacy if he/she called in a medication by 5:00 P.M., then the medication would arrive by 2:00 A.M., the next day. If a medication was out, he/she would first check the Pixis (a locked stat safe box with medications) to see if the medication was in there and call the pharmacy for a refill. If a medication needed a prescription any time between 7:00 A.M. - 5:00 P.M., he/she would walk to the physician's office and get it signed.
During an interview on 10/30/24 at 4:00 P.M., RN E said she just became the DON a week ago and was the previous ADON. She worked as a night nurse (Nurse Manager) on 08/19/24 and 08/20/24. She received Resident #1's cenobamate 150 mg per mouth at 8:00 P.M., on 08/19/24, and placed it in the nurse's medication cart because it came with a narcotic sheet, and nurses pass a lot of the narcotics. The nurses only pass narcotics on the night shift. There were typically two nurses on the night shift, and they were the ones who sign in the medications. If a medication was out, then she would call the pharmacy immediately and if a medication was missing, she would look in all the med carts. She would expect CMTs to not document Resident #1's cenobamate was not here and they should have looked for it. She said the resident missing five days of the medication could have been avoided.
During a telephone interview on 11/05/24 at 12:32 P.M., CMT L said he/she worked on 08/20/24, and 08/22/24, that week. He/She remembered charting the medication was not available which should have shown up as a progress note, but couldn't say for sure if he/she followed up with the charge nurse to report it. The nurses sign for the pharmacy deliveries at night, the medication was put in the wrong cart, and all the carts were not searched. Any narcotic medications that come in were locked up by the nurses.
During a telephone interview on 11/05/24 at 12:38 P.M., CMT H said he/she couldn't recall any instances of a resident missing doses of medication during that time frame. If that happened, he/she would inform the charge nurse and would chart that they were waiting on the pharmacy.
During a telephone interview on 11/05/24 at 12:46 P.M., LPN D said he/she doesn't normally work on the hall Resident #1 resided and didn't remember if he/she was working during the time frame when the doses were missed. If a CMT reported a resident was out of medication, he/she would call the pharmacy. The pharmacy usually made two runs per day, around 12:00 A.M., and 3:00 P.M., but if a resident was out of medication, they could put in for a STAT delivery. The nurses received the meds from the pharmacy and controlled drugs were put in the locked box, but the others were put in the CMT carts.
During a telephone interview on 11/05/24 at 5:30 P.M., the Compliance Officer for the Pharmacy said Resident #1's cenobamate 150 mg was a controlled substance and it had a 30 day prescription. He/She said on 07/15/24, 14 tablets were sent to the facility; on 07/31/24, another 14 tablets were sent to the facility; and on 08/15/24, two tablets were sent to the facility to fulfill the 30 day prescription. LPN D signed for those two tablets at 12:32 A.M. on 08/16/24. On 08/16/24, a request was made for a refill, but the insurance refused due to needing a new signed prescription. On 08/19/24, 14 tablets were delivered at 6:07 P.M., and RN E signed for the medication. On 08/29/24, 14 tablets were delivered and LPN F signed for the medication. The pharmacy had a cut off time at 12:00 P.M., for refill requests, and those made by 12:00 P.M., would arrive the same day. Typically refill requests were sent in three days prior to a resident's last dose of medication. The pharmacy also did another delivery at 1:00 A.M., for new prescriptions that were called in after the 8:00 P.M., cut off time.
COMPLAINT #MO 242770
Aug 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to protect the rights of four of six sampled residents (Residents #1, #2, #3 and #4) by establishing a pract...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to protect the rights of four of six sampled residents (Residents #1, #2, #3 and #4) by establishing a practice of revoking the resident's right to temporarily leave the facility by a physician's order for residents who are their own person, in response to that resident not following the rules established in the newly updated admission policy. The facility census was 86.
Review of the facility's policy titled, Possession and/or use of Illegal Substances, Marijuana, and Alcohol, dated 2/1/2023 and updated 6/5/2024, showed:
- If the facility staff identifies items or substances that pose risks to residents' health and safety and are in plain view, staff will confiscate them and alert their immediate supervisor;
- The staff will notify resident's attending physician if resident is found with or suspected to be displaying signs/symptoms of being under the influence of illegal substance, alcohol, and/or marijuana to determine necessary interventions and/or medications/treatments they may need to hold;
- The facility and/or physician also reserves the right to conduct alcohol and drug testing, suspend or discontinue out of facility pass (also referred to as Leave of Absence (LOA));
- In order to maintain and ensure the health and safety of the resident, other residents, and staff, the facility reserves the right to and may conduct a search of the premises including the resident room and/or resident belongings if the facility determines through observation or report that a resident may have access to illegal substances, drug paraphernalia, unauthorized or unprescribed alcohol, or marijuana that they brought into the facility or secured from an outside source.
1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 05/23/24, showed:
- An admission date of 11/17/23;
- The resident is cognitively intact;
- Diagnoses of anxiety disorder (characterized by an unpleasant state of inner turmoil and dread), muscle weakness, paraplegia (impairment in motor function of the lower extremities), and Bi-Polar Disorder (conditions of episodes of mania and depression);
- The resident is his/her own responsible party.
Review of the progress notes dated 07/02/24, showed Resident #1 had signed an updated smoking, alcohol, marijuana and drug policy and had noted documenation of violation of this said policy. The note did not indicate what the violation was or what may have occurred. The note said the resident's room was searched and no contraband was found. The resident was educated on the policy again then nursing management notified resident that his/her LOA privileges had been revoked per the policy.
Review of the resident's Physician Order Sheet (POS), dated June 2024, showed an order dated 06/06/24 which revoked the resident's LOA privileges and required all in house family visits to be supervised.
During an interview on 08/14/24 at 11:30 A.M., the Administrator (ADM) said the resident is his/her own responsible party and liked to wheel him/herself to the gas station down the road. The ADM said she felt this was dangerous as the resident has to go onto the highway to get there. On the date the doctor revoked the LOA, the resident had come back to the facility and appeared drunk. That is why the doctor ordered the revocation of the LOA. The ADM said there is no way to provide protective oversight if the resident is allowed to go LOA.
During an interview on 08/14/24 at 1:00 P.M., Resident #1 said the staff are not nice. Resident #1 said first they took away his/her right to go out of the facility, then they met his/her family at the door, accused them of having drugs, wouldn't allow them in and refused to let him/her go with them. Resident #1 said he/she is his/her own responsible party and should be allowed to leave the building any time he/she wants as long as he/she signs out. What he/she does out of the facility is his/her business. The resident is currently in the hospital and is hoping not to return to the facility.
2. Review of Resident #2's Significant Change MDS dated [DATE] showed:
- An admission date of 12/29/2023;
- The resident is cognitively intact;
- Diagnoses of Traumatic Ischemia of the Muscle (a condition that occurs when a severe injury happens and prevents adequate blood supply to the muscles), anxiety disorder and heart disease (a heart condition that includes diseased vessels, structural problems and blood clots);
- The resident is his/her own responsible party.
Review of the resident's POS, dated July 2024, showed an order, dated 07/03/24, to revoke the resident's LOA privileges.
During an interview on 08/14/24 at 2:30 P.M., Resident #2 said he/she had gone with family and did not come back until the next morning. The staff then had his/her doctor write an order he/she cannot go out with family again. Resident #2 said he/she is his/her own responsible party and does not understand why he/she can't go out with whomever he/she wishes.
3. Review of Resident #3's Quarterly MDS dated [DATE] showed:
- An admission date of 06/24/24;
- The resident is cognitively intact;
- Diagnoses of paraplegia and Traumatic Brain Disorder (brain dysfunction caused by a blow to the head);
- The resident is his/her own responsible party.
Review of Resident #3's Progress Notes, dated 06/03/24, showed staff saw the resident headed up the hill toward the highway in his/her electric wheelchair. The staff stopped the resident and asked what he/she was doing. The resident responded going for a stroll. The staff educated the resident on this not being safe. The physician wrote an order, dated 06/03/24, to revoke Resident #3's LOA privileges.
During an interview on 08/14/24 at 2:15 P.M., Resident #3 said he/she got a new electric wheelchair and wanted to go to the quick stop and get some snacks. As he/she was headed out, staff stopped him and now he/she cannot go off the premises or LOA. Resident #3 said he/she felt this is wrong, and he/she has lost what ever little independence he/she had left.
4. Review of Resident #4's Quarterly MDS, dated [DATE], showed:
- The resident admitted on [DATE];
- The resident is cognitively intact;
- Diagnoses of anxiety disorder and Chronic Kidney Disease (long standing disease to the kidneys causing renal failure);
- The resident is his/her own responsible party.
Review of the resident's progress note, dated 06/06/24, showed the resident may not go LOA for violating the smoking policy by lighting a cigarette in the dining room after his/her father passed away. They informed the resident of the revocation of LOA privileges on 06/06/24.
Review of the resident's July 2024 POS, showed an order to revoke his/her LOA privileges.
During an interview on 08/23/24 at 8:00 A.M., Resident #4 said someone told the staff he/she had marajuana in his/her room. The staff searched the room and found it and now he/she is not allowed to leave the facility with or without family. The resident said it is not right, but what can we do?
During an interview on 08/14/24 at 11:45 A.M., the Regional Nurse (RGN) said the facility revised the policy and had all the residents to sign it. This policy is to not allow any contraband in the facility such as drugs or alcohol. This gives the facility the right to search the resident's personal belongings and their room. The facility will search any room if they suspect drugs or alcohol whether the policy is signed or not. She said this is the only way to provide protective oversight. If a resident goes off site and violates this policy by partaking in drugs or alcohol, staff will have the facility physician to sign an order to revoke the resident's right of LOA of any kind. They will tell the resident they cannot leave if this order is invoked. This included residents that are cognitively intact with no Guardian. If they leave during a revokation, the facility will discharge the residents for leaving against medical advice (AMA).
During an interview on 08/14/24 at 1:50 P.M., the facility Medical Director (MD) said the only way to protect the facility from residents who go out and may drink or use drugs while on LOA is to invoke an order to prevent them from leaving. He said this is to protect the resident, the facility and himself/herself.
During an interview on 08/14/24 at 4:20 P.M., the Director of Nurses (DON) said she does not have any choice but to prevent the residents from leaving if there is an physician' order. This is the only way to protect the physician's rights and make sure the residents don't use drugs that interfere with medications.
During an interview on 08/14/24 at 4:25 P.M. the Social Worker (SW) said he/she is concerned with the possible resident rights issues with the new policy. The SW said he/she reached out to the Omsbudsman for advice, but got no response. The SW said Resident #3 had tried to leave the premises and they believed he/she might purchase alcohol, so they revoked the resident's LOA privileges. Resident #2 came back to the facility drunk after being with family and they revoked the residen's LOA privileges. It is a form of punishment.
Complaint #MO239985
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 F0563
(Tag F0563)
Could have caused harm · This affected 1 resident
The facility failed to protect the rights of one of the six sampled residents (Resident #1) by prohibiting the visitation of a family member based on the facility's assumption that the family member w...
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The facility failed to protect the rights of one of the six sampled residents (Resident #1) by prohibiting the visitation of a family member based on the facility's assumption that the family member was in possession of Marijuana. The census was 86.
Record review of the policy on Possession and/or use of Illegal Substances, Marijuana, and Alcohol dated 2/1/2023 and updated 6/5/2024, showed:
- If the facility staff identifies items or substances that pose risks to residents ' health and safety and are in plain view, they will confiscate them and alert their immediate supervisor;
- The staff will notify resident ' s attending physician if resident if found with or suspected to be displaying signs/symptoms or being under the influence of illegal substance, alcohol, and /or marijuana to determine necessary interventions and/or medications/treatments they may need to hold;
- The facility and/or physician also reserves the right to conduct alcohol and drug testing, suspend or discontinue out of facility pass (LOA);
- In order to maintain and ensure the health and safety of the resident, other residents, and staff, the facility reserves the right to and may conduct a search of the premises including the resident room and /or resident belongings if the facility determines through observation or report that a resident may have access to illegal substances, drug paraphernalia, unauthorized or unprescribed alcohol, or marijuana that they brought into the facility or secured from an outside source;
- To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing in illegal substances;
- All employees, residents, family members, visitors and others that enter the facility may be subject to an investigation of substance abuse to include tests that detect the use of alcohol, illegal drugs, marijuana, or any substance which is unlawful under the Controlled Substance Act.
1. Record review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 05/23/24, showed:
- An admission date of 11/17/23;
- The resident is cognitively intact;
- Diagnoses of anxiety disorder (characterized by an unpleasant state of inner turmoil and dread), muscle weakness, paraplegia (impairment in motor function of the lower extremities), and Bi-Polar Disorder (conditions of episodes of mania and depression);
- The resident is his/her own responsible party.
Review of Progress Notes showed:
- On 07/02/24, staff noted the resident had signed an updated smoking, alcohol, marijuana and drug policy and has noted documentation of this said policy. Nursing management notified resident that his/her LOA privileges had been revoked per the policy;
- On 08/03/24, staff noted the Administrator (ADM) had been informed by other residents in the facility that Resident #1 said his/her family was visiting and bringing in drugs for sale. The family came to visit and the ADM refused to allow them into the building. This triggered Resident #1 into a behavioral episode where he attacked several staff members and had to taken to the emergency room via emergency services.
Review of the resident's Physician Order Sheet (POS) for June 2024 showed an order to revoke the resident's LOA privileges and all visits were to be supervised supervised dated 06/06/24.
During an interview on 8/14/2024 at 11:30 A.M., the Administrator (ADM) said on 08/03/24 Resident #1 had been telling other residents that a family member was coming to visit and bringing the resident marijuana. The ADM did not investigate the rumors or speak with the resident prior to the visitor's arrival. When the resident's family member arrived, the ADM told them to leave and come back another time. The ADM did not indicate there had been any other issues with the family bringing in drugs previously, nor did she say they had ever found marajuana or other contraband in the resident's room. This ADM did not discuss her concerns with the resident or his/her family. The ADM did not offer a supervised visit for the resident and his/her visitors. The resident was upset they had to leave. The resident was not allowed to leave with them. The ADM said this caused Resident #1 to have a catastrophic event and the police were called to remove the resident from the building. An ambulance came and took the resident to the emergency room. The ADM said she filed assault charges against the resident. All the residents have signed an updated policy saying they will not have drugs or alcohol in the building.
During an interview on 08/14/24 at 11:45 A.M., the Regional Nurse (RGN) said, the facility revised the policy and had all the residents to sign it. This policy prohibits any contraband in the facility such as drugs or alcohol. This policy also gives the facility the right to search the resident's personal belongings, their room and restrict visitors, however whether they sign or not staff will search resident rooms for contraband.
During an interview on 08/14/24 at 1:00 P.M., Resident #1 said the staff are not nice. They would not allow his/her family in the building because they accused the family member of having drugs. They also would not allow him/her to go out with them. Resident #1 said no one talked to or asked him about any drugs. He/She said the ADM has had it out for him/her since she got there. Resident #1 said he/she is their own responsible party and he/she can do whatever he/she chooses just like the ADM. The resident is still in the hospital and will have surgery the following day for an unrelated issue. The resident does not want to return to the facility.
During an interview on 07/14/24 at 4:25 P.M. the Social Worker (SW) said she is concerned with the possible resident rights issues with the new policy. She said she has reached out to the Omsbudsman for advice. The new policy is a form of punishment. The SW said she was not at the facility the day of the ADM refusing to allow the family to visit. She is aware of the new policy and feels there are resident rights issues.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0567
(Tag F0567)
Minor procedural issue · This affected multiple residents
Based on record review and interview, the facility failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for two residents (Resident #6 and #7) out of ...
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Based on record review and interview, the facility failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for two residents (Resident #6 and #7) out of a sample of 14. Additionally, the facility also failed to allow residents access to resident funds on an ongoing basis. This had the potential to affect all residents the facility managed funds for. The facility census was 86.
1. Record review of the facility maintained Resident Trust Ledger for the period 07/01/24 through 08/19/24, showed the following withdrawal from Resident #6's account:
Date Amount Description
07/30/24 $50.00 Resident Advance Cash
Record review on 08/19/24 of the facility maintained paperwork for Resident #6's Resident Trust Ledger, showed Resident #6's handwritten name with no written authorization by Resident #6 and/or financial guardian for the listed withdrawal.
During an interview on 08/19/24 at 1:52 P.M., the Business Office Manager said the handwritten name for the withdrawal listed was not Resident #6's signature. The staff member's initials that were next to Resident #6's handwritten name were for a previous staff member that worked at the facility and is no longer employed at the facility.
2. Record review of the facility maintained Resident Trust Ledger for the period 07/01/24 through 08/19/24, showed the following withdrawal from Resident #7's account:
Date Amount Description
08/16/24 $50.00 Resident Advance Cash
Record review on 08/19/24 of the facility maintained paperwork for Resident #7's Resident Trust Ledger, showed Resident #7's cursive written name.
During an interview on 08/19/24 at 2:08 P.M., Resident #7 said he/she scribbles his/her name and the cursive written name was not his/her signature.
During an interview on 08/19/24 at 1:50 P.M., the Business Office Manager said the cursive written signature for the withdrawal was not Resident #7's signature and Resident #7 signs with a scribble and did not know who signed for Resident #7.
3. Record review of the facility maintained Resident Trust Ledger for the period 07/01/24 through 08/19/24, showed Resident #11 had a balance of $44.00 as of 08/19/24.
During an interview on 08/19/24 at 12:31 P.M., Resident #11 said he/she has not been able to get cigarettes for about one month.
During an interview on 08/19/24 at 1:09 P.M., the Activities Supervisor said he/she asked for money for cigarettes for Resident #11 but there was no resident petty cash available in the office when the request was made.
4. During an interview on 08/19/24 at 2:50 P.M., the Business Office Manager said he/she would ask residents if they can wait until the next day if there was no cash in the office. The Receptionist used to have a key to the office but there is no longer anyone at the front desk in the evening, Monday through Friday.
Complaint MO00240601
Jun 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of on-going assessments, monitoring, and comm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of on-going assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #14) out of one sampled resident. The facility's census was 83.
Review of the facility's policy, Dialysis Care Guidelines, revised 03/15/24, showed:
- Communication between the dialysis provider and center staff should included written communication that includes daily weights, changes in condition or mood, response to treatment, and evaluation of the vascular site;
- Whether resident receives hemodialysis out of center or receives dialysis in house, communication is essential for continuity of care;
- Be cognizant of medications ordered and timing of administration;
- If resident is feeling ill or exhibiting unusual symptoms before the scheduled session, communicate symptoms to the out patient dialysis center and physician to ascertain if dialysis should be delayed;
- Review transfer forms post dialysis, for any pertinent information;
- Check fistula for bruit (an abnormal whooshing sound heard through a stethoscope) and thrill (a palpable murmur that feels like a ringing phone or a fly trapped in one's hand) daily.
1. Review of Resident #14's Physician's Order Sheet, dated June 2024, showed:
- admitted on [DATE];
- Order for dialysis on Mondays, Wednesdays and Fridays;
- Obtain vital signs before and after dialysis;
- Upon return from dialysis, palpate (examine by touch) for thrill and listen for bruit, document findings.
Review of the resident's medical record showed:
- Diagnoses of end stage renal disease (a medical condition where the kidneys can no longer function to filter wastes or excess fluids from the blood), hypertension (high blood pressure) and muscle weakness;
- Documentation of the communication reports, dated 03/27/24-06/05/24, showed 16 out of 31 opportunities missed;
- Documentation of the completed communication reports, dated 03/27/24-06/05/24, showed three out of 15 opportunities missed to document vital signs after the resident returned to the facility on either communication report or in chart.
During an interview on 06/06/24 at 8:30 A.M., Resident #14 said he/she goes to dialysis on Mondays, Wednesdays and Fridays. The resident said staff did not observe his/her arm every time and he/she used to have a red or green folder that was taken to dialysis and brought back, but had not seen that in a while. He/She had asked staff on a couple occasions if they need to look at his/her arm upon return, but had been told they didn't need to see it.
During an interview on 06/06/24 at 8:40 A.M., Registered Nurse (RN) M said they have a communication form that is sent with the resident to dialysis. They send any missed medications for that morning, vital signs, and check for thrill and bruit. Upon return, vital signs are checked along with thrill and bruit. The dialysis center is responsible for the pre and post weights.
During an interview on 06/07/24 at 10:00 A.M., Licensed Practical Nurse (LPN) L said they send a dialysis form with the resident and it is brought back to fill out, but LPN L hasn't seen the form in awhile. The assessments are put into the Treatment Administration Record (TAR).
During an interview on 06/07/24 at 3:20 P.M., the Administrator and Director of Nursing (DON) said they would expect dialysis communication forms to be filled out and sent with resident to dialysis center, then upon return to facility, completed again.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pests out and to keep the garbage contained in the dumpster. The facilit...
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Based on observation and interview, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pests out and to keep the garbage contained in the dumpster. The facility census was 83.
The facility did not provide a sanitation policy.
Observations of the dumpster, located in front of the facility, showed:
- On 06/06/24 at 8:05 A.M., the dumpster with the lid opened with visible bags and other miscellaneous items;
- On 06/6/24 at 1:00 P.M., the dumpster with the lid opened with visible bags and other miscellaneous items;
- On 06/6/24 at 4:10 P.M., the dumpster with the lid opened with visible bags and other miscellaneous items;
- On 06/07/24 at 8:15 A.M., the dumpster with the lid opened.
During an interview on 06/07/24 at 10:00 A.M., the Dietary Manager said she would expect staff to ensure the trash dumpster lids are closed after staff discard trash and other miscellaneous items. Housekeeping is also responsible for disposing of trash in the dumpsters.
During an interview on 06/07/24 at 10:49 A.M., the Housekeeping and Laundry Manager said housekeeping empties trash and he/she would expect staff to ensure the lids are closed after staff discard trash and other miscellaneous items.
During an interview on 06/07/24 at 3:20 P.M., the Administrator and Director of Nursing said they would expect the trash dumpster lids to be closed after staff discard trash and other miscellaneous items.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for one resident (Resident #336...
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Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for one resident (Resident #336) out of 18 sampled residents. The facility's census was 83.
Review of the facility's policy, Infection Prevention and Control Program, revised 05/15/23, showed:
- All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment;
- All staff shall demonstrate competence in relevant infection control practices;
- Direct care staff shall demonstrate competence in resident care procedures established by our facility;
- Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.
Review of the facility's policy, Hand Hygiene, dated 09/01/21, showed:
- Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;
- Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table; before applying and removing personal protective equipment (PPE), including gloves, before and after handling clean or soiled dressings, linens etc., before performing resident care procedures, after handling items potentially contaminated with blood, body fluids, secretions or excretions, when, during resident care, moving from contaminated body site to a clean body site;
- The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.
Observation on 06/06/24 at 9:00 A.M. of wound care for Resident #336 showed:
-Licensed Practical Nurse (LPN) A did not sanitize or wash hands prior to gathering supplies from wound cart, then created a clean barrier on the resident's bed;
-LPN A sanitized hands and donned gloves, removed the old dressing from the resident's left leg using scissors obtained from his/her pocket, then placed the soiled scissors onto the clean barrier;
-With the same soiled gloves, LPN A picked up sanitizer bottle from the barrier on bed and placed on top of the resident's refrigerator;
-LPN A removed gloves and sanitized hands using the now soiled, hand sanitizer bottle;
-LPN A donned gloves, obtained gauze pads soaked with wound cleanser and cleaned two wound areas with the same gloves;
-LPN A placed Santyl (an ointment used to removed dead tissue from wounds allowing to heal) on a cotton swab and applied to one wound;
-With the same soiled gloves, LPN A obtained a wooden stick applicator, applied Santyl to second wound and removed gloves;
-LPN A sanitized hands, donned clean gloves and wrapped the resident's foot with a gauze bandage and secured with tape;
-With the same soiled gloves, LPN A picked up pressure relieving boot and placed on the resident's lower leg, then touched and adjusted the resident's pillow under his/her leg;
-LPN A placed soiled trash in a bag, removed gloves and left room without washing hands, while holding the soiled scissors;
-LPN A cleaned scissors with an alcohol wipe and ungloved hands;
-LPN A placed the soiled bottle of sanitizer and wound cleanser back on side bin of the wound cart;
-LPN A carried bag of trash to soiled utility room and immediately came back out without washing hands.
During an interview on 06/06/2024 at 10:10 A.M., LPN A said his/her process of wound care is to get supplies together, introduce self, wash hands, put gloves on, take old bandages off, remove gloves, place new dressing, bag trash, take bags out, and wash hands. He/She should clean dirty scissors with alcohol wipes and should not place dirty/soiled scissors on a clean barrier. He/She uses the same hand sanitizer and same wound cleaner on the wound cart for every resident with wounds.
During an interview on 06/07/2024 at 1:00 P.M., LPN B/Infection Preventionist said he/she would expect staff to sanitize hands going in and going out of rooms. Scissors should be cleaned with saniwipes/bleach wipes. Wound cleanser and hand sanitizer on the wound cart should stay on the wound cart. Wound cleanser and hand sanitizers should absolutely not be taken off the wound cart and used on multiple residents and taken into multiple rooms. Staff should absolutely change gloves between different wounds. Staff should absolutely sanitize/wash hands before leaving the room.
During an interview on 06/07/2024 at 3:20 P.M., the Director of Nursing (DON) said he/she would expect staff to wash their hands between dirty and clean and to change their gloves between dirty and clean when providing resident care and would expect shared equipment or items to be cleaned according to policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This practice had the potential to ...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This practice had the potential to affect all residents. The facility census was 83.
Review of the facility's policy titled, Pest Control Program, revised 09/01/22, showed an effective pest control program is defined as measures to eradicate and control and contain common household pests (bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats).
Review of the facility's Policy Explanation and Compliance Guidelines, dated 09/21/21 and revised on 09/01/22, showed:
- Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis;
- Facility will ensure that appropriate chemicals are used to control pests, but can be used safely inside the building without compromising resident health;
- Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated;
- Facility will utilize a variety of methods in controlling certain seasonal pests, flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations;
- Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures, dumpster area.
Review of monthly pest control invoices, dated 12/16/23 to 05/28/24, showed:
- December service targeted unknown;
- January service targeted mice and cockroaches;
- February service targeted mice and cockroaches;
- March service targeted mice and cockroaches;
- April service targeted mice and cockroaches;
- May service targeted mice, cockroaches, and ants;
- Monthly pest control invoices did not include any services targeting flies.
1. Observation of Room D-9 on 06/04/24 at 1:38 P.M. showed approximately six flies in the room, flying around and landing on the resident at times.
During an interview on 06/04/24 at 1:38 P.M., the resident in Room D-9 said staff always leave the meal trays and it draws flies.
2. Observation of Room A-1 on 06/04/24 at 12:30 P.M. showed six flies, flying around the room and landing on the resident's bedside table.
3. Observation of Room B-6 showed:
- On 06/04/24 at 12:57 P.M., two flies in room;
- On 06/05/24 at 12:35 P.M., two flies in room.
4. Observation of Room A-2 on 06/06/24 at 02:36 P.M. showed eight flies flying around the room during wound care.
5. Observation on 06/06/24 at 2:06 P.M., showed residents swatted at a fly during the resident council meeting.
6. Observation on 06/07/24 at 12:45 P.M., showed a fly buzzing around a resident while eating in the dining room.
During an interview on 06/07/24 at 9:33 A.M., Housekeeper K said there are flies on A and B hall now mainly. The residents opening their windows and people coming in and out of doors draw the flies into the facility.
During an interview on 06/07/24 at 09:59 A.M., Licensed Practical Nurse (LPN) L said that he/she hasn't seen any flies on C hall yet today, but noticed about 50 at the nurses station earlier today.
During an interview on 06/07/24 at 10:00 A.M., Certified Medical Assistant (CMA) J and Certified Medication Technician (CMT) I said that there are flies in all hallways, but mainly on A and B hallway at this time.
During an interview on 06/07/24 10:10 A.M., LPN B said that with the change of seasons, residents are opening windows and opening doors when going to smoke, causing the flies to come into the facility.
During an interview on 06/07/24 at 10:49 P.M., the Housekeeping and Laundry Manager said the flies are horrible. Housekeeping does everything they can to keep things clean to help with the fly situation. Part of the problem is there is no longer a system in place for staff to communicate to the new pest control company on where in the building needs sprayed. They used to have someone that would come once a week and spray the entire building, but now the new one comes once a month and only sprays five rooms per visit. There is no process in place to determine which rooms he sprays, and they have no way to communicate to him where they see flies and bugs. They used to have a book where they would make a note for him, and now they don't have that.
During an interview on 06/07/24 at 3:20 P.M., the Administrator and Director of Nursing said they would expect the facility to be free from pests.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure safe smoking interventions for two residents (Resident #48 and #336) out of four sampled residents who smoke and four ...
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Based on observation, interview, and record review, the facility failed to ensure safe smoking interventions for two residents (Resident #48 and #336) out of four sampled residents who smoke and four residents (Resident #24, #73, #76, and #80) outside the sample. The facility census was 83.
Review of the facility's policy, Resident Smoking, revised 03/03/22, showed:
- This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents;
- Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan;
- Safe smoking measures will be documented on each resident's care plan and communicated to staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan;
- Smoking materials of residents requiring supervision with smoking will be maintained by community staff.
Review of the facility's Courtyard Rules, undated, showed all smoking must be supervised. Residents are not allowed to smoke without staff supervision.
Review of the facility's designated smoking times showed smoking times to be 9:00 A.M., 11:00 A.M., 1:30 P.M., 4:00 P.M., and 7:30 P.M.
1. Review of Resident #24's medical record showed:
- An admission date of 11/17/23;
- Diagnoses of spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly), paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
Review of the resident's Smoking Assessment, dated 05/23/24, showed:
- The resident requires supervision;
- The resident needs the facility to store lighter and cigarettes;
- The plan of care is used to ensure the resident is safe while smoking.
Review of the resident's care plan, with a review date of 06/05/24, showed:
- Resident is dependent on tobacco and noncompliant with facility smoking policy;
- Resident has a history of refusing to turn over smoking materials and has been educated on the risks;
- The resident requires supervision while smoking;
- The resident's smoking supplies are stored at the nursing station;
- Notify social worker or administrator immediately if it is suspected resident has violated facility smoking policy;
- Instruct resident about the facility policy on smoking locations, smoke times, facility rules, and safe smoking practice.
Review of the resident's behavior notes showed:
- On 04/19/24, when writer knocked on the door and stated Social Services, resident was seen with lighter and shoving something under his/her blanket;
- On 03/27/24, a nurse heard door alarm to courtyard going off, observed resident outside smoking. Resident refused to hand over cigarettes or lighter and continued to smoke about half the cigarette before coming in;
- On 02/24/24, resident observed outside in the courtyard smoking. Asked resident to please put out cigarette and hand them over; it is not the designated time to smoke. Resident refused to hand them over but did put out the cigarette and come in;
- On 02/17/24, resident advised of smoking policy and need to have front entrance secure. Resident violated policy when smoking at front entrance;
- On 01/22/24, resident was non compliant with smoking policy this shift, going outside multiple times thru the alarm doors prior to temperatures reaching 32 degrees and outside of smoke times without staff supervision;
- On 01/20/24, resident going outside to smoke after being educated about current outside temperature. Current temperature is 19 degrees, and facility smoking policy states that residents are not taken outside by staff at scheduled smoke times when temps are below 0 degrees. Resident disregards education and is going outside anyway.
Observation of the resident on 06/07/24 at 9:45 A.M. showed the resident smoked unsupervised with other residents in the courtyard.
2. Review of Resident #48's medical record showed:
- An admission date of 03/22/24;
- Diagnoses of altered mental status (a change in mental function), muscle weakness, and cognitive social or emotional deficit following nontramatic intracerebral hemorrhage (problems with attention, memory, executive functioning, and information processing after a brain bleed).
Review of the resident's Smoking Assessment, dated 04/24/24, showed:
- The resident has cognitive loss;
- The resident requires supervision;
- The resident needs the facility to store lighter and cigarettes;
- The plan of care is used to ensure the resident is safe while smoking.
Review of the resident's care plan, revised 06/05/24, showed:
- Resident is dependent on tobacco and noncompliant with facility smoking policy;
- Resident has a history of refusing to turn over smoking materials and has been educated on the risks;
- All smoking materials to be kept in lock box;
- Instruct resident about the facility policy on smoking locations, smoke times, facility rules, and safe smoking practice;
- Notify social worker or administrator immediately if it is suspected resident has violated facility smoking policy;
- Provide reminders related to facility smoking policies/procedures and encourage compliance.
Observation of the resident on 06/07/24 at 9:45 A.M. showed the resident smoked unsupervised with other residents in the courtyard.
3. Review of Resident #73's medical record showed:
- An admission date of 01/17/24;
- Diagnoses of muscle weakness, lack of coordination, and nicotine dependence.
Review of the resident's Smoking Assessment, dated 05/14/24, showed:
- Resident with visual deficit;
- The resident requires supervision;
- The resident needs the facility to store lighter and cigarettes;
- The plan of care is used to ensure the resident is safe while smoking.
Review of the resident's care plan, revised 04/24/24, showed:
- Resident is dependent on tobacco and noncompliant with facility smoking policy at times;
- Instruct resident about the facility policy on smoking locations, smoke times, facility rules, and safe smoking practice;
- Notify social worker or administrator immediately if it is suspected resident has violated facility smoking policy;
- The resident requires supervision while smoking;
- The resident's smoking supplies are stored in a lock box under staff supervision.
Review of the resident's behavior notes showed on 01/22/24, resident was non compliant with smoking policy this shift, going outside multiple times thru the alarm doors prior to temps reaching 32 degrees and outside of smoke times without staff supervision.
Observation on 06/05/24 at 10:55 A.M. showed the resident outside smoking with other residents and no staff present.
4. Review of Resident #76's medical record showed:
- An admission date of 12/04/23;
- Diagnoses of muscle weakness, cognitive communication deficit (trouble reasoning and making decisions while communicating), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).
Review of the resident's Smoking Assessment, dated 05/13/24, showed:
- The resident has cognitive loss;
- The resident requires supervision;
- The resident needs the facility to store lighter and cigarettes;
- The plan of care is used to ensure the resident is safe while smoking.
Review of the resident's care plan, revised 06/05/24, showed:
- Resident is dependent on tobacco and noncompliant with facility smoking policy;
- Resident has a history of refusing to turn over smoking materials and has been educated on the risks;
- Notify social worker or administrator immediately if it is suspected resident has violated facility smoking policy;
- Instruct resident about the facility policy on smoking locations, smoke times, facility rules, and safe smoking practice.
Observation on 06/07/24 at 11:43 A.M. showed the resident outside in the courtyard smoking by himself/herself and said staff won't come outside to supervise him/her. The Social Services Designee (SSD) came outside to the courtyard and told the resident that he/she missed smoke break and gave the resident smoke break times. The SSD said the resident needed to give his/her cigarettes and lighter to her, and the resident said he/she is not going to give them to her. The SSD replied that they'll have to find placement for him/her elsewhere if he won't give up the cigarettes and lighter.
5. Review of Resident #80's medical record showed:
- An admission date of 04/25/24;
- Diagnoses of cognitive communication deficit, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), and muscle weakness.
Review of the resident's Smoking Assessment, dated 05/13/24, showed:
- The resident requires supervision;
- The resident needs the facility to store lighter and cigarettes;
- The plan of care is used to ensure the resident is safe while smoking.
Review of the resident's care plan, revised 06/03/24, showed:
- The resident is a smoker and may not always be compliant with smoking policy;
- Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station;
- Instruct resident about the facility policy on smoking locations, times, and safety concerns;
- Notify charge nurse immediately if it is suspected resident has violated facility smoking policy;
- The smoking policy was reviewed and accepted by the resident and/or resident family;
- The resident requires supervision while smoking.
During an interview on 06/04/24 at 12:40 P.M., the resident said he/she keeps his/her cigarettes and lighter with him/her all the time. He/she keeps his/her lighter because if staff had it, he/she would never get it back. He/she smokes two cigarettes a day and had a pack of cigarettes in his/her t-shirt pocket. He/she keeps extra packs of cigarettes in a nightstand that has a lock and key.
6. Review of Resident #336's medical record showed:
- An admission date of 04/15/24;
- Diagnoses of cognitive communication deficit, muscle weakness, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).
Review of the resident's Smoking Assessment, dated 04/24/24, showed:
- The resident requires supervision;
- The resident needs the facility to store lighter and cigarettes;
- The plan of care is used to ensure the resident is safe while smoking.
Review of the resident's care plan, revised 04/24/24, showed:
- Resident is dependent on tobacco and noncompliant with facility smoking policy;
- Instruct resident about the facility policy on smoking locations, smoke times, facility rules, and safe smoking practice;
- Notify social worker or administrator immediately if it is suspected resident has violated facility smoking policy;
- The resident requires supervision while smoking;
- The resident's smoking supplies are stored in a lock box, under staff supervision.
Observation of the resident on 06/07/24 at 9:45 A.M. showed the resident smoked unsupervised with other residents in the courtyard.
During an interview on 06/05/24 at 12:50 P.M., the SSD said the residents were not supposed to keep cigarettes and/or lighters on them. The problem was the residents would get them when they were on leave of absence or their family members would bring to them. This had been a big issue and the facility had been trying to resolve it.
During an interview on 06/05/24 at 3:30 P.M., Licensed Practical Nurse (LPN) A said the residents go out to the smoking area without supervision in between set smoking times. When going out to the smoking area, this turns the door alarm on and he/she said this happens daily with staff being aware.
During an interview on 06/07/24 at 9:50 A.M., Resident #24, #48, and #336 collectively said there are never enough staff to supervise the residents while they smoke. It happens on a daily basis.
During an interview on 06/07/24 at 3:20 P.M., the Administrator and Director of Nursing said staff is supposed to keep the cigarettes and lighters and all residents have supervised smoking with set smoking times.
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 store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had t...
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Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 83.
Review of the facility's policy, Food Safety Requirement, dated 09/01/21, showed:
- It is the policy of this facility to procure food from sources approved or considered satisfactory by the federal, state, and local authorities;
- Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.
1. Observation on 06/04/24 at 12:14 P.M., 06/05/24 at 12:14 P.M. and on 06/06/2024 at 10:45 P.M. of the walk-in refrigerator showed dirt and debris in the bottom of the refrigerator.
2. Observation on 06/04/24 at 12:14 P.M., 06/05/24 at 12:14 P.M. and on 06/06/2024 at 10:45 P.M. of the walk-in freezer showed:
- Food items not labeled or dated, including bags of corn on the cob, meat, and cinnamon rolls;
- Dirt and debris in the bottom of the freezer.
3. Observation on 06/04/24 at 12:14 P.M., on 06/05/24 at 12:14 P.M. and on 06/06/2024 at 10:45 P.M. of the kitchen showed:
- Debris on the shelves and counters throughout the kitchen;
- Debris on the floors throughout the kitchen;
- [NAME] grime build up on the commercial dishwasher;
- A build up of a brown substance in the fryer;
- Debris on the front of the fryer around the knobs;
- Debris on the table top on which the fryer was placed;
- Carbon build up on the convection oven doors;
- Black substance build up on the flat griddles;
- A black substance on the ceiling above the walk in freezer;
- [NAME] grime build up on the drinking cups;
- A plastic container on the counter labeled thickener with no use by date listed.
4. Observation on 06/04/24 at 12:14 A.M., on 06/05/24 at 12:14 P.M., and on 06/06/24 at 10:45 P.M. of the dry food storage room showed:
- Three dented cans of vegetable soup and one large dented can of apples;
- A large white plastic tub with a bag of opened powdered milk with a large blue scoop in the bottom of the plastic tub which had dirt and debris in it;
- Scattered dirt and debris throughout the room.
During an interview on 06/05/24 at 10:50 A.M., the DM said if she has dented cans of food, she will take a picture of them and send it to their food supplier and they will replace them. The dented can of apples was turned the other way on the shelf and she hadn't noticed it, but will see about sending them back.
During an interview on 04/19/24 at 3:20 P.M., the Administrator and Director of Nursing said they would expect food to be labeled and dated. They would expect clean dishes to be free from grime build up, stored in an area free from dirt and debris. They would expect kitchen equipment to be maintained in working order and free from grime build up and debris. They would expect floors and surfaces to be free from spills, dirt and debris.
Oct 2023
1 deficiency
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. The facility failed to separate six residents (Resident #1, #2, #3, #4, #5, and #6) who tested positive for COVID-19 from six residents (Resident #7, #8, #9, #10, #11 and #12) who had tested negative for COVID-19, which placed the residents at an increased risk of contracting COVID-19 due to prolonged exposure. The facility census was 85.
The Administrator, Director of Nursing, and Assistant Director of Nursing/Infection Preventionist were notified on 10/13/23 at 04:00 P.M. of an Immediate Jeopardy (IJ) which began on 10/01/23. The IJ was removed on 10/13/23, as confirmed by surveyor onsite verification.
Review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/8/23, showed:
- The recommendations in the guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency;
- The Infection Prevention and Control (IPC) recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing;
- Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom;
- If cohorting, only patients with the same respiratory pathogen should be housed in the same room;
- Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection.
Review of the facility's policy Covid-19 Infection Control Practices, undated, showed:
- Transmission based precautions (TBP) should be used with all positive residents and symptomatic residents until tested negative 48 hours after first negative test;
- TBP should be used on asymptomatic residents when resident residing on unit with ongoing Covid positive residents;
- They should be removed from TBP after day seven following the exposure (day of exposure is day 0);
- If resident is suspected or confirmed to be Covid positive, put in a single room with a private restroom. Keep door closed if possible;
- Limit transport and movement of the resident outside of the room unless medically necessary;
- Communicate information about the resident to appropriate personnel before transferring them to other departments in the facility;
- HCP who enter the room of a resident with suspected or confirmed Covid infection should adhere to TBP and use a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filter or higher, gown, gloves, and eye protection;
- Duration of TBP for Residents with Covid Infection: Residents with mild to moderate illness who are not moderately to severely immunocompromised: at least ten days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms have improved;
- Duration of TBP for Residents with Covid Infection: Residents who are asymptomatic throughout their infection and are not moderately to severely immunocompromised: at least ten days have passed since their first positive viral test.
1. Review of the facility's Testing Tracker showed staff documented Resident #1 tested positive for COVID-19 on 10/08/23. Review of the report showed the resident's roommate Resident #7 tested negative for COVID-19 on 10/08/23, 10/10/23, and 10/12/23.
Review of Resident #1's Nurse's Notes, dated 10/08/23, showed the resident with symptoms of being hoarse and having a cough.
Observation on 10/13/23 at 01:32 P.M. showed Resident #1 and Resident #7 residing in the same room.
2. Review of the facility's Testing Tracker showed staff documented Resident #2 tested positive for COVID-19 on 10/08/23. Review of the report showed the resident's roommate Resident #8 tested negative for COVID-19 on 10/08/23, 10/10/23, and 10/12/23.
Review of Resident #2's Nurse's Notes, dated 10/08/23, showed the resident was asymptomatic.
Observation on 10/13/23 at 10:06 A.M. showed Resident #2 and Resident #8 residing in the same room.
3. Review of the facility's Testing Tracker showed staff documented Resident #3 tested positive for COVID-19 on 10/08/23. Review of the report showed the resident's roommate Resident #9 tested negative for COVID-19 on 10/08/23, 10/10/23, and 10/12/23.
Review of Resident #3's Nurse's Notes, dated 10/03/23, showed the resident was asymptomatic.
Observation on 10/13/23 at 10:06 A.M. showed Resident #3 and Resident #9 residing in the same room.
4. Review of the facility's Testing Tracker showed staff documented Resident #4 tested positive for COVID-19 on 10/12/23. Review of the report showed the resident's roommate Resident #10 tested negative for COVID-19 on 10/12/23.
Review of Resident #4's Nurse's Notes, dated 10/12/23, showed no documentation of symptoms.
Observation on 10/13/23 at 03:00 P.M. showed Resident #4 shared a room with Resident #10.
During an interview on 10/13/23 at 3:00 P.M., Resident #10 said Resident #4 has COVID and he/she does stay in the room and sleeps in there.
5. Review of the facility's Testing Tracker showed staff documented Resident #5 tested positive for COVID-19 on 10/10/23. Review of the report showed the resident's roommate Resident #11 tested negative for COVID-19 on 10/10/23 and positive on 10/12/23.
Review of Resident #5's Nurse's Notes, dated 10/10/23, showed the resident was asymptomatic.
Observation on 10/13/23 at 03:03 P.M. showed Resident #5 and Resident #11 residing in the same room.
6. Review of the facility's Testing Tracker showed staff documented Resident #6 tested positive for COVID-19 on 10/01/23. Review of the report showed the resident's roommate Resident #12 tested negative for COVID-19 on 10/03/23, 10/05/23, 10/08/23, 10/10/23, and 10/12/23.
Review of Resident #6's Nurse's Notes, dated 10/01/23, showed the resident with symptoms of sinus congestion. The resident was not moved from the room with Resident #12 until 10/05/23.
During an interview on 10/13/23 at 03:20 P.M., Licensed Practical Nurse (LPN) A said they try to isolate COVID positive residents and use appropriate PPE to care for those residents, and try to move positives together. When asked if she knew why there was still negatives with positives, he/she said I cannot answer that.
During an interview on 10/13/23 at 02:00 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said they track when residents test positive and when they are recovered, and residents are considered recovered after having two negative tests 48 hours apart if they were asymptomatic. The ADON/IP said residents who were positive were moved to E hall. When asked about specific residents who have not been separated, she said they did not move them due to not having a room available. She said some were moved in the beginning, then on 10/08/23 when there were several more positives, E hall was full so they didn't move them. The DON said residents won't stay in their rooms anyway so there isn't much point in moving them. The DON and ADON/IP said it is hard to move residents around due to having [NAME] and [NAME] bathrooms.
During an interview on 10/13/23 at 4:00 P.M., the Administrator said he was unaware that positive and negative residents were in the same room, and they should have been separated. The plan is to separate all positive residents from negative residents immediately and, if any further COVID-positive residents are identified, they will be immediately moved to a room with a COVID-positive roommate or a private room.
Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
MO00225796
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to make prompt efforts to resolve grievances for two of three sampled residents (Residents #1 and #2), and had the potential to effect all res...
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Based on interview and record review, the facility failed to make prompt efforts to resolve grievances for two of three sampled residents (Residents #1 and #2), and had the potential to effect all residents of the facility. The census was 96.
Record review of the facility's policy titled Resident and Family Concerns/Complaints, dated 1/4/2022 showed:
- The Concern/Complaint Officer is responsible for overseeing the concern/complaint process, receiving and tracking complaints and concerns through to their conclusion;
- Concerns/Complaints may be verbal or written;
- All staff involved shall make efforts to resolve quickly;
- The investigation shall include:
- The date and time of the alleged incident;
- The circumstances surrounding the alleged incident;
- The location of the alleged incident;
- The names of any witnesses;
- The resident's account of the alleged incident;
- The employee's account of the alleged incident;
- Recommedications for a corrective action.
- The written decision will include at a minimum:
- The date received;
- The steps taken to investigate;
- A summary of findings;
- A statement confirming or not confirming the allegations;
- Any corrective action and the date made.
1. Record review of a written customer concern dated 07/26/23 showed:
- Resident #1's family completed a written greivance regarding CNA A;
- The family reported CNA A told Resident #1 I would rather be dead than old, old people make me sick;
- The family reported the resident told CNA A to get away from him/her and the CNA A replied you will be sorry you said that.
There was no evidence facility staff completed an investigation regarding the customer concerns nor followed up with the resident or the resident's family.
During an interview on 08/15/2023 at 11:50 A.M., Resident #1 said:
- He/she reported to the charge nurse, and submitted a written grievance about the rude comments by CNA A;
- No staff member ever interviewed the resident regarding this matter.
2. Record review of a written customer concern sheet, dated 07/18/23, showed:
- Resident #2 completed a written greivance regarding CNA A;
- CNA A told the resident you are just being lazy and he/she should be able to go to the toilet alone.
There was no evidence facility staff completed an investigation regarding the customer concerns nor followed up with the resident or the resident's family.
During an interview on 08/15/2023 at 12:00 P.M., Licensed Practical Nurse (LPN) B said he/she had received many grievances from Residents #1 and #2 regarding CNA A. LPN B said all written grievances were given to the Assistant Director of Nurses (ADON). LPN B said he/she was later informed the grievances had been lost. LPN B said he/she thought someone told her CNA A had been terminated, but was unsure of the details.
During an interview on 08/15/2023 at 12:15 P.M., the ADON said she had heard about Resident #1 and the CNA A. She visited with CNA A and was told there were no issues between CNA A and the Resident. The ADON said she did not investigate further and never spoke with the resident. The ADON said she should have done an investigation.
During an interview on 08/15/2023 at 12:30 P.M., CNA A said:
- There were never any issues with any of the reported residents;
- He/she said they all get along and there have never been any bad words between them;
- He/she denied the allegations and said he/she has always provided good care to the residents;
- He/she said the facility won't allow her to work the hall they are on now but was unable to provide information on who gave him/her that direction.
During an interview on 08/15/2023 with the Social Service Worker (SSW), she said:
- She is the grievance officer;
- The reports she received in writing from Resident #2 and Resident #1's family, she gave to the ADON;
- She said when she gets the concerns she just forwards them and does not provide any other input to the concern or investigation just allows the staff involved to deal with it.
During an interview on 08/15/2023 at 2:30 P.M., Resident #2 said:
- CNA A had informed the resident to use the bathroom on their own;
- This was reported verbally to LPN B and a written report made;
- No staff member ever interviewed or spoke with the resident regarding this matter;
- The resident said it was his/her understanding CNA A no longer was employed.
During an interview on 08/15/2023 at 2:35 P.M., the Director of Nurses (DON) said:
- She had not been made aware of any of these greivances until this date;
- It had been her understanding that CNA A no longer worked at the facility and she had never met CNA A;
- She said the policy should have been followed and an investigation completed.
MO0222583
Dec 2022
22 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #25) out of 20 sample...
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Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #25) out of 20 sampled residents exposed after staff left the resident's room. The census was 94.
Record review of the facility's Resident Rights policy, dated 9/1/21, showed:
- The resident with the right to be treated with respect and dignity;
- Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits and meetings.
1. Observation of Resident #25 showed:
- On 11/29/22 at 2:39 P.M., the resident lay in bed with the door open, in a shirt and brief, and uncovered;
- On 11/20/22 at 3:45 P.M., the resident lay in bed with the door open, in a shirt and brief, and uncovered;
- The resident visible from the hallway.
Record review of the resident's medical record showed:
- Diagnoses of Alzheimer's Disease (progressive mental deterioration), cognitive communication defect, and urinary incontinence;
- Severe cognitive impairment.
Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/7/22, showed:
- The resident totally dependent on staff for dressing, bed mobility, transfers, and toileting;
- The resident always incontinent of bowel and bladder.
During an interview on 11/29/22 at 3:45 P.M., Certified Nursing Assistant (CNA) F said residents should be covered. The divider should be pulled or the door should be closed for those who will not keep themselves covered with a blanket.
During an interview on 12/1/22 at 3:45 P.M., Licensed Practical Nurse (LPN) K, said that it was expected to keep a resident covered or provide privacy. It was not acceptable to walk down the hall and see a cognitively impaired resident only wearing a brief or naked.
During an interview on 12/2/22 at 1:40 P.M., the Director of Nursing (DON) said residents should be kept covered or provided privacy. It was not acceptable to see residents in their room while only wearing a brief and shirt when walking down the hall.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order for the code status (the t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order for the code status (the type of emergent treatment a person would or wouldn't receive if their heart or breathing were to stop) for two residents (Resident #26 and #52) out of 20 sampled residents. The facility census was 94.
Record review of the facility's Residents' Rights Regarding Advance Directives (a written statement of a person's wishes regarding medical treatment) policy, revised on [DATE], showed:
- The facility will support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive;
- On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive;
- Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff;
- Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions.
1. Record review of Resident #26's medical record on [DATE] showed:
- An admission date of [DATE];
- No documentation of the resident's code status on the face sheet;
- No order for the code status on the resident's Physician's Order Sheet (POS).
Record review of the resident's care plan showed:
- The resident with a do not resuscitate (DNR) (a medical order written by a physician which instructs health care providers not to provide cardiopulmonary resuscitation (CPR) (an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped)) code status, dated [DATE].
Record review of the Code Status binder at the nurses station showed:
- No documentation of the resident's code status.
Record review of the resident's Hospice binder showed:
- The Outside The Hospital Do Not Resuscitate Request form showed the resident be a DNR, signed by the resident's family, and without a physician's signature, dated [DATE].
During an observation on [DATE] at 4:32 P.M., Licensed Practical Nurse (LPN P) was unable to locate the code status for Resident #26 on his/her face sheet or on the POS. LPN P was unable to locate the Code Status Binder at the nurses station. He/she found a DNR Request Order form within the resident's hospice binder without a physician's signature.
During an interview on [DATE] at 10:42 A.M., the resident said he/she was not ready to die and wanted the facility staff to perform life saving measures and try to save him/her. He/she wanted to be a full code status (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive).
During an interview on [DATE] at 1:40 P.M., LPN O said he/she discussed the resident being his/her own responsible party and that the resident wanted a full code status instead of a DNR with the hospice nurse on this date.
2. Record review of Resident #52's medical record showed:
- An admission date of [DATE];
- No documentation of the resident's code status on the face sheet;
- No order for the code status on the resident's POS, dated [DATE].
During an interview on [DATE] at 4:32 P.M., LPN P said a resident's code status was in the Code Status Binder or in the resident's chart. He/she said if no code status was found, he/she would assume the resident was a full code. Staff could also look in the Hospice binders, if the resident was on hospice, but the staff cannot go by that code status sheet because it is not the facility's record.
During an interview on [DATE] at 6:10 P.M., the Director on Nursing (DON) said she would expect to find a resident's code status by looking in the resident's medical record. She said it should also be in the Code Status binder at the nurses station. If no code status was found, the resident would be considered a full code. She would expect an order to be signed by a physician or a telephone order confirmed by two nurses with a physician, while in route to be signed. The Assistant Director of Nursing (ADON) took the orders to be signed by the physician to the physician's office.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #36 and #66) out of seven sampled residents. The facility's census was 94.
Record review of the facility's Bed Hold policy, revised April 2017, showed:
- The bed hold policy will be reviewed with the resident, designated family member, and/or the resident's legal representative;
- Before a resident will be transferred to a hospital or goes on therapeutic leave, a written Bed Hold policy will be given to the resident, designated family member, and/or the resident's legal representative;
- In case of an emergency transfer, the resident, designated family member, and/or the resident's legal representative will be issued a copy of the Bed Hold policy within 24 hours by sending a copy with the resident's records at the time of the transfer.
1. Record review of Resident #36's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 9/13/22;
- No documentation with notification for the bed hold policy provided to the resident and/or the resident's responsible party.
2. Record review of Resident #66's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 9/21/22;
- No documentation with notification for the bed hold policy provided to the resident and/or the resident's responsible party.
During an interview on 12/1/22 at 2:04 P.M. , the Director of Nursing (DON) said she would expect a bed hold policy be given to the resident, designated family member, and/or the resident's legal representative at the time of a transfer to the hospital.
During an interview on 12/1/22 at 2:12 P.M., the Administrator said she would expect a bed hold policy be given to the resident, designated family member, and/or the resident's legal representative at the time of a transfer to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimal Data Set (MD...
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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 document a complete and accurate Minimal Data Set (MDS), a federally mandated assessment to be completed by the facility, for three residents (Resident #16, #46, and #86) out of 20 sampled residents. The facility census was 94.
Record review of the facility's Resident Assessment - Resident Assessment Instrument (RAI) policy, revised 8/18/2022, showed:
- This facility makes a comprehensive assessment instrument of each resident's needs, strengths, goals, life history and preferences using the RAI specified by the Centers for Medicare and Medicaid Services (CMS).
- The results of the assessment will be used to develop, review, and revise the resident's comprehensive care plan.
1. Observation of Resident #16 on 11/29/22 at 2:51 P.M. showed:
- The resident sat in dining room with a Foley catheter (a tube inserted into the urinary bladder to drain the urine) collection bag that hung from the frame of his/her Broda chair (a wheelchair that reclines).
Record review of the resident's Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, showed:
- An admission MDS, dated [DATE], indicated the resident with a Foley catheter;
- A quarterly MDS, dated [DATE], indicated the resident without a Foley catheter.
Record review of the Physicians Order Sheet (POS), dated December 2022, showed:
- No order to discontinue the Foley catheter.
During an interview on 12/2/22 at 10:30 A.M., the MDS Coordinator said that if a resident had a Foley catheter, it should be reflected on the resident's MDS.
2. Record review of Resident #46's quarterly MDS, dated [DATE], showed:
- The resident received anticoagulant (a blood thinner) medication;
- The resident's MDS did not reflect an accurate assessment of the medication.
Record review of the resident's POS, dated December 2022, showed:
- An order for aspirin 81 milligram (mg) by mouth one time a day for the prevention of a cardiovascular (the heart and the blood vessels) event, dated 6/29/22;
3. Record review of Resident's #86's admission MDS, dated [DATE], showed:
- The resident received anticoagulant medication;
- The resident's MDS did not reflect an accurate assessment of the medication.
Record review of the resident's POS, dated December 2022, showed:
- An order for aspirin 81 mg by mouth one time a day for the prevention of a cardiovascular event, dated 10/14/22.
During an interview on 12/6/22 at 2:40 P.M., the MDS Coordinator said if a resident had a physician's order for aspirin, it should not reflect as an anticoagulant on the resident's MDS.
During an interview on 12/6/22 at 2:45 P.M., the Director of Nursing (DON) said she would not expect a resident's MDS to reflect the resident received an anticoagulant medication when the resident was only an aspirin regimen. She would expect a resident's Foley catheter to be reflected on the MDS.
During an interview on 12/6/22 at 3:02 P.M., the Administrator said if a resident had a physician's order for aspirin, it should not reflect as an anticoagulant on the resident's MDS. She said a resident's Foley catheter should be reflected on the MDS.
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 develop and implement a baseline care plan consistent with the resident's specific conditions, needs, and risks within 48 hours of admissio...
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Based on interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs, and risks within 48 hours of admission which included the minimum healthcare information necessary to provide care for one resident (Resident #52) out of five sampled residents. The facility's census was 94.
Record review of the facility's Baseline Care Plan policy, dated 6/2/22, showed:
- The facility will develop and implement a baseline care plan for each resident;
- The care plan will be developed within 48 hours of admission;
- It will include the minimum healthcare information necessary to properly care for a resident including, but not limited to the initial goals based on admission orders, medical provider orders, dietary orders, therapy services, and social services;
- The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment and other information;
- Once needs, goals and interventions were established, it will be documented in a designated format;
- A written summary of the baseline care plan will be provided to the resident and representative, in a language that can be understood;
- The person providing the written summary of the baseline care plan shall obtain a signature verifying it was provided and make a copy for the medical record;
- If the summary was provided by phone, the nurse shall indicate the discussion, sign the summary and make a copy before mailing it to the resident/representative.
1. Record review of Resident #52's medical record showed:
- An admission date of 11/4/22;
- Diagnoses of repeated falls, chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), malignant neoplasm of the colon (colon cancer), and moderate protein-calorie malnutrition (significant weight loss);
- No baseline care plan completed.
During an interview on 12/1/22 at 3:30 P.M., the Assistant Director of Nursing (ADON) said he/she would expect all new admissions to have baseline care plans started within 24 hours of admission, but was unable to find one for this resident, so apparently it was not completed. He/she would expect the charge nurse to complete the baseline care plan in the proper time frame.
During an interview on 12/6/22 at 3:20 P.M., the Director of Nursing said a new resident's baseline care plan should be completed within 24 hours of admission, and she would expect the admitting nurse to have that completed within that time frame.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for two residents (Resident #9 and #55) ou...
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Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for two residents (Resident #9 and #55) out of 20 sampled residents. The facility census was 94.
Record review of the facility's Care Plan policy, dated 6/2/22, showed:
- The facility will develop and implement a comprehensive person centered care plan for each resident;
- The care plan will be consistent with the resident rights, professional standards of practice, medical provider orders and resident's goals and preferences;
- It will include measurable objectives and timeframes to meet a resident's special medical, nursing, mental and psychosocial needs that will be identified in the resident's comprehensive assessment.
1. Record review of Resident #9's medical record showed:
- An admission date 8/5/22;
- Diagnoses of congestive heart failure (CHF) (a condition in which the heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), major depressive disorder (MDD) (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety (intense, excessive and persistent worry and fear about everyday situations);
- An order for buspirone (an anti-anxiety medication) 10 milligram (mg) give two tablets by mouth three times a day for anxiety, dated 11/2/22;
- An order for trazodone (an antidepressant medication) 100 mg tablet give three tablets by mouth at bedtime for MDD, dated 8/5/22;
- A smoking assessment, dated 8/5/22, showed the resident required supervision;
- No order for the use of oxygen.
Observations of the resident showed:
- On 11/29/22 at 3:03 P.M., the resident sat in a wheelchair in his/her room with oxygen on at 3.5 liters by nasal cannula (a tube delivering oxygen to a person's nose);
- On 11/30/22 at 9:53 A.M., the resident sat in a wheelchair in his/her room with oxygen on at 3.5 liters by nasal cannula;
- On 12/1/22 at 8:30 A.M., the resident sat in a wheelchair in his/her room with oxygen on at 3.5 liters by nasal cannula.
Observations of the resident showed:
- On 11/30/22 at 11:10 A.M., the resident sat outside smoking and supervised by staff;
- On 12/1/22 at 4:05 P.M., the resident sat outside smoking and supervised by staff.
Record review of the resident's care plan, dated 8/16/22, showed:
- Did not address the resident's oxygen use with interventions;
- Did not address the resident's smoking with interventions;
- Did not address the resident's diagnoses of MDD or anxiety with interventions;
- Did not address the resident's use of anti-anxiety or antidepressant medications with interventions.
2. Record review of Resident #55's medical record showed:
- An admission date of 7/22/22;
- Diagnoses of MDD, malignant neoplasm of bronchus and lung (a malignant cancer that originates in the bronchi or other parts of the lung); constipation (infrequent bowel movements).
Record review of the resident's bowel log showed:
- The resident had no bowel movements documented from 9/17/22 through 9/21, 6 days;
- The resident had no bowel movements documented from 9/25/22 through 10/2/22, 7 days;
- The resident had no bowel movements documented from 11/3/22 through 11/9/22, 5 days.
Record review of the resident's care plan, dated 7/23/22, showed:
- Did not address diagnosis of MDD with interventions;
- Did not address diagnosis of constipation with interventions.
During an interview on 12/2/22 at 11:20 A.M., the Director of Nursing (DON) said she would expect the care plan to reflect the resident's condition and needs with individualized interventions.
During an interview on 12/6/22 at 2:50 P.M., the MDS Coordinator said the care plans should be individualized, reflecting the resident's condition, care and preferences.
During an interview on 12/13/22 12:01 P.M., the Assistant Director of Nursing (ADON) said the
MDS Coordinator was responsible for the care plans, they should reflect the resident's condition, and be individualized. They should include interventions for bowel and bladder concerns, depression, and the medications administered for their use. Care plans should be completed at least quarterly and updated with changes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician orders for five residents (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician orders for five residents (Resident #9, #16, #17, #26 and #53) out of 20 sampled residents. The facility census was 94.
Record review of the facility's Oxygen Administration policy, dated 5/4/22, showed oxygen to be administered under orders of a medical provider, except in cases of emergency.
1. Record review of Resident #9's medical record showed:
- admission date 8/5/22;
- Diagnoses of congestive heart failure (CHF) (a condition in which the heart doesn't pump blood as well as it should) and chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe).
Record review of the resident's Physician Order Sheet (POS), dated 11/30/22, showed no physician's order for oxygen.
Observations of the resident showed:
- On 11/29/22 at 3:03 P.M., the resident sat in a wheel chair in his/her room with oxygen in use at 3.5 liters per minute (3.5 L/min) by nasal cannula;
- On 11/30/22 at 9:53 A.M., the resident sat in a wheel chair in his/her room with oxygen in use at 3.5 L/min;
- On 12/1/22 at 8:30 A.M., the resident sat in a wheel chair in his/her room with oxygen in use at 3.5 L/min.
During an interview on 12/13/22 at 12:03 P.M., the Assistant Director of Nursing (ADON) said she would expect a resident with oxygen to have a physicians order.
Record review of the facility's Catheter Care policy, revised on 7/14/22, showed:
- Residents with indwelling catheters will receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters used;
- Catheter care will be performed every shift and as needed by nursing personnel.
2. Observation of Resident #16 on 11/29/22 at 2:51 P.M., showed the resident sat in the dining room with a Foley catheter (a tube inserted into the urinary bladder to drain the urine) collection bag hanging from his/her Broda chair (a wheelchair that reclines).
Record review of the resident's POS, dated 11/30/22, showed:
- No order for a Foley catheter;
- No order for Foley catheter care.
During an interview on 12/2/22 at 12:00 P.M., the ADON said that there should be an order for the use and care of the catheter, or to continue it if the resident came from the hospital with it. She said the physician will be contacted to address the catheter order.
3. Observation of Resident #17 showed:
- On 11/29/22 at 3:34 P.M., the resident lay in bed with oxygen in use at 2 L/min;
- On 12/1/22 at 9:00 A.M., the resident lay in bed with oxygen in use at 2 L/min.
Record review of the resident's medical record showed:
- The resident readmitted to the facility on [DATE];
- Diagnoses of chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and CHF;
- No physician's order for oxygen on the resident's POS, dated 11/30/22.
During an interview on 12/6/22 at 3:00 P.M., Licensed Practical Nurse (LPN) O said any resident that used oxygen should have a physician's order for it, and the order should show what setting it should be on.
4. Record review of Resident #26's medical record showed:
- A admission Summary progress note, dated 10/27/22, admitted to hospice;
- The quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff), dated 11/9/22, indicated the resident received hospice care;
- The resident's care plan, revised on 11/29/22, the resident chose hospice services and with an admission date of 10/27/22.
Record review of the resident's POS, dated 11/30/22, showed:
- No physician's order to admit to hospice.
5. Record review of Resident #53's medical record showed:
- A hospice admission date of 7/30/21;
- The quarterly MDS, dated [DATE], indicated the resident received hospice care;
- The resident's care plan, revised on 10/21/22, the resident's admission date of 7/30/21 to hospice.
Record review of the resident's POS, dated 12/1/22, showed:
- No physician's order to admit to hospice.
During an interview on 12/1/22 at 3:30 P.M., the Director of Nursing (DON) said Resident's #26 and #53 did not have an order to admit to hospice on their POS. Residents should have an order for admission to hospice and it would be corrected.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide consistent resident care for activities of da...
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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 consistent resident care for activities of daily living (ADL's) when the residents went an extended amount of time without showers for four residents (Resident #28, #55, #66, and #71) out of 20 sampled residents, and one resident (Resident #1) outside the sample. The facility census was 94.
Record review of the facility's Resident Showers policy, revised 5/4/22, showed:
- The facility will assist residents with bathing to maintain proper hygiene and help prevent skin issues;
- The policy did not address how often showers to be given.
Record review of the facility's Bed Baths policy, revised 11/10/22, showed:
- Document the procedure.
1. Record review of Resident #1's medical record showed:
- An admission date of 9/16/16;
- Diagnoses of morbid obesity, major depressive disorder (MDD) (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Diabetes Mellitus (DM) (a condition that affects the way the body processes blood sugar), muscle weakness, difficulty walking, and need for assistance for personal care.
Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 9/19/22, showed:
- Cognitive status intact;
- Supervision with assist of one staff for dressing;
- Limited assist of one staff for toileting;
- Supervision with assist of one staff for personal hygiene;
- Physical help in part of one staff for supervision for bathing.
During an interview on 11/30/22 at 10:26 A.M., the resident said it had been almost six weeks since he/she had a shower, and it was not unusual to go one and a half to three weeks without a shower. The staff said they didn't have the time or enough staff.
Record review of the resident's shower sheets for August 2022 through November 30, 2022, showed;
- In August, the resident received a shower on 8/24/22;
- In September, the resident received a shower on 9/14/22;
- In October, the resident received showers on 10/5/22, 10/16/22, and 10/19/22;
- In November, the resident received a shower on 11/30/22;
- Shower sheets showed six showers documented out of 35 opportunities, a total of 29 opportunities for showers missed.
2. Record review of Resident #28's medical record showed:
- admission date 10/21/22;
- Diagnoses of Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should), acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), muscle weakness, and obesity (excessive body fat).
Review of the resident's quarterly MDS, dated [DATE], showed:
- Cognitive status intact;
- Supervision with set up dressing;
- Independent with set up for personal hygiene;
- Physical help limited to transfer only for bathing.
Review of the resident's shower sheets for 10/21/22 through 11/30/22, showed;
- In October, no showers documented;
- In November, documentation showed on 11/18/22 the resident refused a shower, and the resident was in the hospital 11/21/22 through 11/24/22;
- Shower sheets showed one shower documented refused, resident reported two showers given, out of nine opportunities, a total of six showers missed.
During an interview on 11/30/22 at 9:50 A.M., the resident said he/she had been here over a month and had only had two showers. When one was asked for, the staff said they were short staffed and would have to do it another day. So he/she had been just washing up at the bathroom sink as good as could be done, but would like to have the two showers a week the facility said would be given.
3. Record review of Resident #55's medical record showed:
- admission date 7/22/22;
- Diagnoses MDD, malignant neoplasm of bronchus and lung (a malignant cancer that originates in the bronchi or other parts of the lung); constipation (infrequent bowel movements) (BM), tracheostomy(an opening created in the front of the neck so a tube can be inserted into the windpipe to help breath), muscle weakness, and abnormal posture.
Review of the resident's quarterly MDS, dated [DATE], showed:
- Cognitive status intact;
- Extensive assist of one staff for dressing;
- Total assist of one staff for toileting
- Extensive assist of one staff for personal hygiene;
- Physical help in part of one staff for bathing.
During an interview on 11/30/22 at 1:26 P.M., the resident shook his/her head no when asked if received showers twice a week.
Review of the resident's shower sheets for August 2022 through November 30, 2022, showed;
- In August, resident received showers on 8/15/22 and 8/20/22;
- In September, no showers documented;
- In October, resident received showers on 10/18/22, 10/24/22, and 10/31/22;
- In November, the resident received showers on 11/3/22, 11/10/22, and 11/24/22;
- Shower sheets showed eight showers documented out of 35 opportunities, a total of 27 opportunities for showers missed.
4. Record review of Resident #66's medical record showed:
- admission date 7/22/22;
Diagnoses of DM, difficulty in walking, abnormalities of gait and mobility, heart failure, and dependence on renal dialysis (a treatment to clean blood when the kidneys are not able to).
Review of the resident's quarterly MDS, dated [DATE], showed:
- Cognitive status intact;
- Limited assist of two staff for dressing;
- Extensive assist of two staff for toileting
- Extensive assist of one staff for personal hygiene;
- Physical help in part of two staff for bathing.
Review of the resident's shower sheets for August 2022 through November 30, 2022, showed;
- In August, resident received showers on 8/13/22 and 8/27/22;
- In September, resident received showers on 9/15/22 and 9/20/22;
- In October, resident received showers on 10/4/22, 10/15/22, and 10/20/22;
- In November, the resident received showers on 11/8/22, 11/12/22, and 11/29/22.
- Shower sheets showed 10 showers documented out of 35 opportunities, a total of 25 opportunities for showers missed.
5. Record review of Resident #71's admission evaluation showed:
- An admission date of 4/1/22;
- Diagnoses of DM, difficulty in walking, abnormal posture, muscle weakness, heart failure, and fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping).
- Cognitive status intact.
Record review of the resident's care plan, dated 10/6/22, showed:
- The resident to have an ADL self-care performance deficit related to activity intolerance.
Record review of the facility's shower sheets for August 2022 through November 30, 2022, showed:
- The resident received a bed bath on 8/20/22, 10/7/22, 11/8/22 and 11/15/22.
During an interview on 11/30/22 at 10:48 A.M., Resident #71 said he/she does not get showers. The resident received bed baths due to pain when getting out of bed.
During an interview on 11/30/22 at 11:22 A.M., Resident #71 said he/she had not had a bed bath since 11/15/22, and one had not been offered.
During an interview on 11/30/22 at 2:26 P.M., Certified Nursing Assistant (CNA) J said the residents were scheduled for two showers a week and he/she tried to give them, but sometimes there wasn't enough time or staff to help get them done.
During an interview on 11/30/22 at 11:15 A.M., the Nurse Manager said showers were expected to be completed two times a week, and they had been a concern. Currently she was working on audits to monitor them, along with the documentation of them being given or that the resident refused.
During an interview on 12/1/22 at 1:21 P.M., the Administrator said she did not agree that the facility doesn't have enough staff to give showers or at least a bedbath. She would expect the residents to get their two showers a week, if they cant be given on the scheduled day, then on the next day. She said this was a concern and the nurse manager was working on shower audits at this time.
During an interview on 12/13/22 at 12:05 P.M., the Assistant Director of Nursing (ADON) said, showers were scheduled two times a week, they did have residents that refuse repeatedly. Make up showers were done on Sundays if they were missed, it was expected that residents get or at least offered showers two times a week.
MO209931 and MO210302
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure treatment and care of standard of practice by not following the bowel regimen policy for one resident (Resident #55) out of 20 resid...
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Based on interview and record review, the facility failed to ensure treatment and care of standard of practice by not following the bowel regimen policy for one resident (Resident #55) out of 20 residents. The facility census was 94.
Record review of the facility's Bowel Regimen policy, revised 4/5/2022, showed:
- Will monitor the residents bowel movements (BM) and provide clinical best practice interventions as needed for a resident to have regular bowel movements;
- Resident BM's will be evaluated and documented daily;
- If a resident does not have a BM for 72 hours, the clinical team shall be alerted;
- If the resident has any as needed (PRN) orders for bowel elimination assistance, it should be followed;
- If the resident has no PRN order, notify the physician to obtain an order;
- Monitor the resident's response to administration of bowel elimination assistance;
- If no results, notify the physician;
- Evaluate potential causes of constipation and implement interventions as needed to reduce causes.
1. Record review of Resident #55's medical record showed:
- An admission date of 7/22/22;
- Diagnoses of major depressive disorder, malignant neoplasm of bronchus and lung (a malignant cancer that originates in the bronchi or other parts of the lung); and constipation (infrequent BM's).
Record review of the resident's bowel log showed:
- The resident had no bowel movements documented from 9/17/22 through 9/21, six days;
- The resident had no bowel movements documented from 9/25/22 through 10/2/22, seven days;
- The resident had no bowel movements documented from 11/3/22 through 11/9/22, five days.
Record review of the resident's Treatment Administration Record (TAR), dated 10/1/22 through 10/31/22 showed:
- A bisacodyl (a medication used to treat constipation) suppository administered on 10/2/22, after seven days with no BM.
Record review of the resident's nurse's notes showed:
- On 9/22/22, notified the physician of the resident's abdominal pain and constipation and received a new order for abdominal X-rays and to hold the residents enteral (a way of delivering nutrition directly to the stomach through a tube placed through the abdomen into the stomach) feedings;
- On 9/23/22, a nurse attempted to digitally remove fecal material from the resident's rectum and was unsuccessful. Received a new order for Milk of magnesia (MOM) (a medication to treat constipation) and administered it with no results;
- On 9/23/22, received an order to send the resident to the emergency room for evaluation and treatment;
- On 9/24/22 the resident returned to the facility with a new order for Miralax (a medication to treat constipation) 17 grams daily.
During an interview on 12/1/22 at 2:45 P.M., Certified Nursing Assistant (CNA) J said he/she did document BM's. If a resident went two days without a BM, it was reported to the charge nurse. If it continue, he/she just kept telling the charge nurse. It was reported about the resident not having a BM back in September 2022, but he/she was unaware of the other times the resident went over three days with no BM's.
During an interview on 12/2/22 at 2:50 P.M., Licensed Practical Nurse (LPN) N said if a resident had not had a BM in three days,he/she would administer ordered medications if available, and if not, he/she would give the standing order either Miralax or MOM.
During an interview on 12/2/22 at 11:20 A.M., the Director of Nursing (DON) said the facility did have a bowel protocol that should be used, and she was made aware of this occurrence yesterday when it was brought to her attention. If there had been a reoccurrence since then, she would expect the protocol to be followed.
During an interview on 12/13/22 at 12:08 P.M., the Assistant Director of Nursing (ADON) said the documentation system should flag a resident and alert nursing for when the resident had went 72 hours without a bowel movement. The facility had a lot of new staff, and it was possible they were not aware of where to look for it. Education would be completed to make sure everyone was aware. It was expected that the bowel protocol should be followed after 72 hours of no bowel movements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reposition two residents (Resident #13 and #26) out of two sampled ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reposition two residents (Resident #13 and #26) out of two sampled residents who were identified as at risk for pressure ulcers (damage to the skin and/or underlying tissue as a result of pressure). The facility also failed to follow physician ordered wound care orders for one resident (Resident #13) out of two sampled residents. The facility census was 94.
Record review of the facility's Pressure Injury (damage to the skin and/or underlying tissue as a result of pressure) Prevention and Management policy, revised on 3/3/22, showed:
- The purpose will be to prevent avoidable pressure injuries and the promotion of healing existing pressure injuries;
- Intervention will be based on specific factors identified in the risk assessment, skin assessment and any pressure injury assessment;
- Evidence-based interventions for prevention will be implemented for all residents assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but will not limited to: redistribute pressure, minimize exposure to moisture and keep skin clean, provide appropriate pressure-redistributing support surfaces, maintain or improve nutrition and hydration status;
- Evidence-based treatments in accordance with current standards of practice will be provided for all residents with a pressure injury present.
1. Record review of Resident #13's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/3/22, showed:
- An admission date of 4/26/21;
- Diagnoses of multiple sclerosis (MS) (a disease of the central nervous system resulting in muscle weakness and loss of coordination);
- Severely cognitively impaired;
- Required extensive assistance of two staff for bed mobility, transfers, toileting, personal hygiene, and bathing;
- Always incontinent of bowel and to have a urinary catheter (a tube inserted into the bladder through the urethra that allows urine to drain from the bladder for collection);
- At risk of developing pressure ulcers with treatments of a pressure reducing device for the bed and the chair and a turning/repositioning program;
- No pressure ulcers identified.
Record review of the resident's care plan, revised on 12/7/22, showed:
- The resident at risk for a pressure ulcer, initiated on 12/1/22;
- Interventions of administer medications as ordered, education for the resident as to the causes of skin breakdown including transfer/positioning requirements, and follow the facility policies/protocols for the prevention/treatment of skin breakdown.
Record review of the resident's Physician Order Sheet (POS), dated December 2022, showed:
- An order to clean the left lateral ankle wound with normal saline, apply a nickel thick layer of Santyl, cover with optifoam (a silicone adhesive bordered waterproof dressing), and change daily and as needed (PRN).
Observation on 11/30/22 at 10:01 A.M., of Resident #13 showed:
- A dressing to the left lateral ankle, dated 11/28/22;
- The facility failed to apply a new dressing on 11/29/22;
- Licensed Practical Nurse (LPN) P washed his/her hands, donned gloves, and removed the old dressing;
- LPN P, with the same soiled gloves, applied Santyl to all of the wound bed with his/her gloved finger, without use of an applicator;
- LPN P applied the optifoam dressing and dated it 11/30/22;
- LPN P failed to wash/sanitize his/her hands and to change the soiled gloves between the removal of the soiled dressing;
- LPN P failed to cleanse the wound with normal saline as ordered.
- The facility failed to follow physician orders for daily wound care.
Observations of Resident #13 on 12/1/22 showed:
- At 8:15 A.M., 10:30 A.M., 11:40 A.M., 1:15 P.M., 1:45 P.M., and 2:50 P.M. the resident lay in bed on his/her back;
- The resident lay on the bed on his/her back in the same position for six hours and 35 minutes and staff did not provide incontinent care.
During an interview on 11/30/22 at 10:20 A.M., LPN P said the wound should have been cleansed with normal saline after removing the old dressing for Resident #13. The old dressing did have a date of 11/28/22, which would mean it had not been changed, but he/she did not take care of the resident on 11/29/22. The resident should be repositioned as much as possible, at least every couple of hours to prevent pressure ulcers. The pressure ulcer happened due to the resident's legs being left crossed for an extended amount of time and assessed as a Stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous tissue layer) due to the escar (dark, dead matter cast off from the surface of the skin).
2. Record review of Resident #26's admission MDS, dated [DATE], showed:
- An admission date of 10/7/22;
- Required extensive assistance of two staff for bed mobility, transfers, dressing, and personal hygiene;
- Required total dependence of two staff for toilet use and bathing;
- Always incontinent of bowel and bladder;
- At risk of developing pressure ulcers with treatments of a pressure reducing device for the bed and the chair, a turning/repositioning program and applications of ointments/medications other than to feet;
- Moisture associated skin damage (caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) identified;
- No pressure ulcers identified.
Record review of the resident's care plan, dated 10/27/22, showed:
- The resident with the potential for impairment to his/her skin integrity, initiated on 10/27/22, and with interventions of avoid scratching and keep hands and body parts from excessive moisture, monitor for and report to the medical director any signs or symptoms of skin breakdown, provide pressure relieving devices if indicated, and provide preventive skin care;
- Bowel incontinence, initiated 10/27/22, with interventions of check the resident every two hours and assist with toileting as needed, provide a bedpan/bedside commode, provide pericare after each incontinent episode;
- Bladder incontinence, initiated 10/27/22, with interventions of clean the resident's peri-area with each incontinence episode, monitor/document for signs and symptoms of an urinary tract infection (UTI) (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), monitor/document/report as needed any possible causes of incontinence.
Observations on 11/30/22 of Resident #26 showed:
- At 8:46 A.M., the resident sat in the dining room in a Geri chair (a reclining chair on wheels). The resident asked if he/she could go back and lay down. Certified Nursing Assistant (CNA) R offered to take the resident and lay him/her down, but he/she said the resident needed a hoyer lift (a mechanical device used to move or transfer a person) to transfer him/her and would need a second staff person to help;
- At 9:08 A.M., CNA R brought incontinent care supplies to the resident's bedside table in the resident's room. The air mattress lay flat on the bedframe and not in working condition. CNA Q said he/she couldn't lay the resident down due to the mattress being unplugged and it would take about an hour to reinflate. The staff did not check nor provide the resident with incontinent care or reposition the resident in the Geri chair.
- 10:25 A.M., Resident sleeping in Geri chair in room with eyes closed, call light in lap. Air mattress noted fully inflated at this time;
- At 11:55 P.M., the resident sat in the Geri chair in his/her room with his/her eyes closed;
- At 12:24 P.M., the resident sat in the Geri chair in the dining room;
- At 12:25 P.M., the incontinent care supplies sat on the bedside table in the resident's room;
- At 2:05 P.M., the resident sat in the Geri chair in his/her room with his/her eyes closed;
- At 2:40 P.M., the two staff transferred the resident from the Geri chair to the bed with a hoyer lift, the resident's brief wet with urine and staff provided incontinent care, and no pressure reduction cushion in the Geri chair;
- The resident sat in the Geri chair in the same position and did not receive incontinent care for five hours and 54 minutes.
Observations on 12/1/22 of Resident #26 showed:
- At 8:10 A.M., the resident sat in the Geri chair in the dining room;
- At 10:30 A.M., the resident sat the in Geri chair in his/her room;
- At 12:30 P.M., the resident sat in the Geri chair in his/her room;
- At 2:05 P.M., two staff transferred the resident from the Geri chair to the the bed with a hoyer lift, the resident's brief soiled with urine and stool and staff provided incontinent care, and no pressure reduction cushion in the Geri chair;
- The resident sat in the Geri chair in the same position and did not receive incontinent care for four hours and 55 minutes.
During an interview on 12/1/22 at 2:55 P.M., CNA J, said he/she would expect total care residents to be turned/repositioned, with briefs and/or clothes checked and changed every two hours and/or as needed.
During an interview on 12/2/22 at 1:15 P.M., the Director of Nursing (DON) said staff should cleanse the wound after removing an old dressing. Dressings should be completed as ordered. An applicator should be used to apply ointment to a wound bed. Residents who were at risk of pressure ulcers should be repositioned throughout the shift.
During an interview on 12/6/22 at 3:30 P.M., the DON said he/she would expect a resident to be repositioned at a minimum every two hours and as needed. He/She said would also expect resident's to be checked and incontinent care to be provided every two hours and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM an...
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Based on observation, interview and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their range of motion. The facility staff failed to perform restorative services as recommended by the occupational therapist (OT) for one resident (Resident #36) out of 5 sampled residents. The facility census was 94.
Record review of the facility's Restorative Nursing Program (RNP) policy, revised, 5/4/2022, showed:
- The facility will provide maintenance and restorative services to maintain or improve a resident's abilities to the highest practicable level;
- Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols;
- The interdisciplinary team, with the support of the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences;
- Nursing personnel will be trained on basic or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight which include assisting residents in adjustment to their disabilities, use of any assistive device, ROM, performing passive range of motion (PROM) for residents who lack active range of motion ability;
- The Restorative Nurse will be responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program will be implemented.
Record review of the facility's Contracture (a shortening or stiffening of the muscles) Management policy, revised 5/4/22, showed:
- Residents will not experience an avoidable reduction in ROM;
- Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM;
- Residents with limited mobility (movement) will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility would be unavoidable;
- The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and the representative will be included in determining these goals and objectives;
- Documentation of the resident's progress toward goals and objectives will include attempts to address any changes or decline in the resident's condition or needs.
1. Record review of Resident #36's medical record showed:
- An admission date of 1/4/2019;
- Diagnosis of spastic quadriplegic cerebral palsy (an inability to control movement, muscle tone, or posture affecting all four limbs, face and trunk).
Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 9/9/22, showed:
- Cognitively impaired;
- Dependent with activities of daily living (ADLs) and self care.
Observations of the resident on 11/29/22 at 3:52 P.M., 11/30/22 at 9:22 A.M., and 12/1/22 at 8:41 A.M., showed:
- Contractures on the bilateral (left and right) upper extremities (arms and hands);
- Contractures on the bilateral lower extremities (legs and feet).
Record review of the resident's care plan, dated 9/16/22, showed:
- Restorative Therapy Program to maintain the resident's ROM to the bilateral upper and lower extremities three to five times a week related to the disease process, limited ROM, limited mobility and musculoskeletal (muscles, bones) impairment;
- Restorative Therapy Program to maintain ankle foot orthosis (AFO) (a positioning support device for the foot and ankle) wear schedule with no complaints of discomfort or redness seven times a week related to the contractures and the limited physical ability.
Record review of the the resident's Restorative Care Program form, dated 10/25/21, showed:
- Maintain the resident's ROM to the bilateral upper and lower extremities;
- Maintain the AFO wear schedule with no complaints of discomfort or redness;
- PROM to the bilateral upper and lower extremities;
- Put on the bilateral AFO every morning;
- The frequency to be three to five times a week;
- The individualized plan remained appropriate as of 8/29/22;
- No documentation of the restorative services provided.
Record review of the resident's therapy progress note, dated 6/29/22, showed:
- The resident screened by OT secondary to the monthly assessment;
- The resident at his/her baseline and not appropriate for skilled therapy;
- The resident to transfer with use of a hoyer lift (a device used to safely transfer a person);
- Dependent for all self care tasks;
- Dependent for functional mobility in the wheelchair (WC);
- The resident used AFO's to his/her bilateral lower extremities while in the WC;
- The resident remained appropriate for the RNP to maintain PROM.
Record review of the Physician's Order Sheet (POS) dated 12/1/22, showed:
- Speech therapy (ST) swallowing evaluation and dysphasia (difficulty swallowing) therapy, dated 7/14/22;
- OT positioning evaluation, dated 6/1/22;
- Physical therapy (PT) evaluation and treatment with frequency and time frame, dated 6/1/22;
- No order for restorative services.
During an interview on 12/1/22 at 2:44 P.M., Certified Occupational Therapist Assistant (COTA) L said once a resident was discharged from therapy services and recommended to a restorative program, the restorative nursing designee should ensure the resident was receiving his/her individualized treatment plan and restorative services were being documented. There were no residents currently on a restorative program and the facility had no restorative program at this time.
During an interview on 12/1/22 02:54 P.M., the Director of Nursing (DON) said she would expect upon a therapy recommendation for restorative nurse program (RNP) a physician's order would be given for restorative nursing with the frequency and the time frame for the resident. She would expect restorative nursing be addressed and revised on the resident's care plan as needed. She would expect documentation of each resident receiving restorative nursing services at the facility. This was her first week as the DON at the facility and she was informed by the therapy department of no restorative program being in place and no residents on a restorative program at this time.
During an interview on 12/1/22 at 3:49 P.M., the Administrator said she would expect the facility to have a restorative nursing program in place to meet the needs of the residents as recommended by the therapy department. She would expect a resident who was care planned for restorative therapy to be receiving restorative nursing services. She would expect documentation for each resident receiving restorative nursing services to be available for review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide proper incontinent care for two residents (Resident #25 and #26) out of two sampled residents. The facility census was...
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Based on observation, interview and record review, the facility failed to provide proper incontinent care for two residents (Resident #25 and #26) out of two sampled residents. The facility census was 94.
Record review of the facility's Perineal Care policy, revised on 5/4/22, showed:
- If the perineum should be grossly soiled, turn the resident on his/her side, remove any fecal material with toilet paper, then remove and discard. Cleanse the buttocks and anus, front to back, vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. Thoroughly dry;
- Reposition the resident in a supine (lying face up) position. Change gloves if soiled and continue with perineal care;
- Remove gloves and discard, perform hand hygiene.
1. Record review of Resident #25's medical record showed:
- An admission date of 9/26/15;
- Diagnoses of Alzheimer's Disease (progressive mental deterioration), cognitive communication defect, and urinary incontinence;
- Severely cognitively impaired;
- Totally dependent on staff for toileting.
Observation of Resident #25 on 11/30/22 at 2:20 P.M., showed:
- Certified Nurse Aide (CNA) F gathered supplies and prepared to provide incontinent care on the resident;
- The resident's brief to be soaked with urine;
- CNA F provided incontinent care for the resident;
- CNA F failed to cleanse the perineal area.
Observation of the resident on 12/1/22 at 2:40 P.M., showed:
- CNA J gathered supplies and prepared to provide incontinent care on the resident;
- The resident's brief to be soaked with urine and fecal material;
- CNA J provided incontinent care for the resident;
- CNA J failed to cleanse the perineal area.
2. Record review of Resident #26's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/27/22, showed:
- An admission date of 10/7/22;
- Required extensive assistance of two staff for bed mobility, transfers, dressing, and personal hygiene;
- Required total dependence of two staff for toilet use and bathing.
- Always incontinent of bowel and bladder;
- At risk of developing pressure ulcers with treatments of pressure a reduction device for the bed and the chair, a turning/repositioning program, and applications of ointments/medications other than to feet;
- The resident with moisture associated skin damage (caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents).
Observation of the resident on 11/30/22 at 2:40 P.M., showed:
- CNA F gathered supplies and prepared to provide incontinent care on the resident;
- The resident's brief to be soaked with urine;
- CNA F provided incontinent care for the resident;
- CNA F failed to cleanse the perineal area.
Observation of the resident on 12/1/22 at 2:21 P.M., showed:
- CNA Q gathered supplies for incontinent care;
- CNA J and CNA Q failed to cleanse the perineal area.
During an interview on 12/6/22 at 3:30 P.M., the Director of Nursing (DON) said she would expect any area that touched the brief to be cleaned, and peri-care to be performed based on standards of practice and the facility policy.
During an interview on 12/1/22 at 2:58 P.M., CNA J said incontinent care should consist of wiping each gluteal fold, then clean down the perineal area, then the buttocks. Should always clean from the front to the back of the perineal area with a clean cloth.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow physician's orders and the facility policy on getting weights on new admissions to monitor the nutritional status for two residents ...
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Based on interview and record review, the facility failed to follow physician's orders and the facility policy on getting weights on new admissions to monitor the nutritional status for two residents (Resident #54 and #55) out of three sampled residents. The facility census was 94.
Record review of the facility's Weight Monitoring policy, revised, 6/2/2022, showed:
- Weight can be a useful indicator of nutritional status;
- Significant unintended changes in weight may indicate a nutritional problem;
- A weight monitoring schedule will be developed upon admission for all residents;
- Weights should be recorded at the time obtained;
- Newly admitted residents should have weights monitored weekly for four weeks;
- If clinically indicated, weights should be monitored daily;
- All other residents' weights should be monitored monthly.
1. Record review of Resident #54's medical record showed:
- An admission date of 11/5/22;
- Diagnoses of dysphagia (difficulty swallowing foods or liquids), aphasia (trouble speaking or understanding other people when speaking), and memory deficit;
- A Physician's order for weekly weights for four weeks from admission, then monthly weights, weekly weights every day shift on Sunday for four weeks, start date of 11/13/22;
- The Treatment Administration Record (TAR), dated 11/1/22 through 11/30/22, showed the resident's weights scheduled but not recorded on 11/13/22, 11/20/22, and 11/27/22.
Record review of the resident's weight record showed:
- An admission weight on 11/5/22 of 133 pounds (lbs);
- On 12/1/22, a weight of 121.4 lbs;
- No documentation for three out of four opportunities for weekly weights;
- The resident with a significant weight loss of 8.7 percent (%) (11.6 lbs) within 26 days;
- The facility failed to follow the facility protocol of weighing the resident weekly for four weeks.
During an interview on 12/1/22 at 3:30 P.M. the Assistant Director of Nursing (ADON) said the facility protocol for all new admissions was to do weekly weights times four weeks, then monthly, so he/she did not know why weekly weights were not completed for that resident.
2. Record review of Resident #55's medical record showed:
- An admission date of 7/22/22;
- Diagnoses of major depressive disorder (a persistently depressed mood and a long-term loss of pleasure or interest in life), malignant neoplasm of bronchus and lung (a malignant cancer that originates in the bronchi or other parts of the lung), and constipation;
Record review of the Physician's Order Sheet, dated 11/30/22, showed:
- Nothing by mouth (NPO), dated 7/22/22 ;
- Enteral feeding (a way of delivering nutrition directly to the stomach through a tube placed through the abdomen into the stomach) of Glucerna (a supplemental nutrition) 1.5 calorie at 55 milliliters per hour (ml/hr) for 20 hours a day, dated 10/24/22;
Record review of the resident's weight record showed:
- No documentation of an admission weight;
- No documentation of weekly weights for four weeks upon admission;
- No documentation of the weights for August and September 2022;
- A weight of 175 pounds (lb) for October 2022;
- A weight of 168.5 lb for November 2022;
- A weight of 172.2 lb for December 2022;
- No documentation for four out of four opportunities for weekly weights;
- No documentation for one out of three opportunities for monthly weights;
- The facility failed to follow the facility protocol of weighing the resident weekly for four weeks and failed weighing the resident monthly for one month.
Record review of the Registered Dietician (RD) New admission Assessment, dated 7/28/22, showed:
- Per the hospital dietitian assessment notes, the resident weighed a 140 pounds (lb) in the hospital;
- Request height and weight.
Record review of the RD notes, dated 8/18/22, showed:
- Waiting on height and weight to be obtained;
- Will request the height and weight.
Record review of the RD notes, dated 10/5/22, showed:
- The resident's height to be 60 inches and the weight to be 175 lb, obese;
- No recommendations except for weekly weights and to adjust the tube feeding as needed.
During an interview on 12/2/22 at 11:15 A.M., the Director of Nursing (DON) said she would expect weights to be done weekly for a resident if that was the physician's order. She knows the facility had a lot of issues and she planned to help get things straightened out. She planned to get specific staff appointed to collect and monitor weights, and to get on board with the RD.
During an interview on 12/6/22 at 12:19 P.M., the DON said the policy was to weigh the residents on admission, weekly for four weeks, and then monthly if stable. That was what she would expect to be done, along with weighing consistently the same way. Resident #55 had only had three weights since admission and had no admission weight. The only weight the resident had upon admission was taken from the hospital weight documented in his/her hospital records. The weights at the facility included the resident's wheelchair weight.
During an interview on 12/13/22 at 12:10 P.M., the ADON said residents should be weighed on admission, weekly for four weeks, then monthly, unless there was a concern. Consistency with weights were expected, and the charting system should alert staff to any discrepancies. A baseline weight on admission was important and should be obtained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and commu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for two residents (Resident #17 and #66) out of two sampled residents. The facility census was 94.
Record review of the facility's Hemodialysis (dialysis) policy, revised March 3, 2022, showed:
- The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice, including an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility;
- The licensed nurse will communicate with the dialysis facility via telephonic or written format, such as a dialysis communication form or other form, that will include but not limit itself to, medication administration (initiated, held or discontinued), vital signs, shunt (a connection from a hemodialysis access point to a major artery) location and status, new labs since last visit, advance directives (a written document stating how a person wants medical decisions to be made if the person no longer has the ability to make those decisions) and code status (the type of emergent treatment a person would or would not want if the heart or breathing stopped), change in condition, and/or medical provider order changes since last visit;
- The facility shall receive a dialysis summary report from the dialysis center upon return from dialysis, if report not received, nursing staff will contact the dialysis center to receive report.
1. Record review of Resident #17's medical record showed:
- admitted to the facility on [DATE];
- Diagnoses of chronic kidney disease stage 4 (severely damaged kidneys that can't filter waste from the blood very well), and dependence on renal dialysis;
- An order for dialysis on every Monday, Wednesday, and Friday at 10:45 A.M., dated 11/30/22;
- No order listed to assess the dialysis shunt location and status before and after treatments;
- No documentation of an assessment of the resident after returning from dialysis treatments;
- No documentation of any communication between the facility and the dialysis clinic.
2. Record review of Resident #66's medical record showed:
- readmitted to the facility on [DATE];
- Diagnosis of end stage renal disease (chronic irreversible kidney failure);
- An order for dialysis three times weekly on Mondays, Wednesdays, and Fridays, dated 9/25/22;
- No documentation of any communication between the facility and the dialysis clinic.
During an interview on 12/6/22 at 1:26 P.M., the Director of Nursing (DON) said she would expect the nurses to assess the resident's vital signs before and after returning from dialysis, to follow the hemodialysis policy, and use the communication log between the facility and the dialysis center.
During an interview on 12/13/22 at 12:12 P.M., the Assistant Director of Nursing (ADON) said the communication form should be filled out and sent to dialysis with the resident, and the dialysis center should fill out their part of the form and return it with the resident. The expectation was for this form to be completed, and dialysis would be contacted if it was not filled out there.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to post the nurse staffing data with all the required components in a clear and readable format. The facility's census was 94.
R...
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Based on observation, interview, and record review, the facility failed to post the nurse staffing data with all the required components in a clear and readable format. The facility's census was 94.
Record review of the facility's Nurse Staffing Posting Information policy, dated 6/2/22, showed:
- The daily staffing sheet will be posted on a daily basis and will contain the facility name, the current date, the current resident census, the total number and the actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift;
- The facility will post daily and at the beginning of each shift.
Observations of the nurse staffing information posted on the wall across from the nurse's station showed;
- On 11/29/22 at 2:03 P.M., the posted nurse staffing information, dated 11/23/22, with no information for 11/29/22;
- On 12/1/22 at 11:26 A.M., the posted nurse staffing information, dated 11/30/22, with no information for 12/1/22;
- On 12/2/22 at 12:58 P.M., the posted nurse staffing information, dated 11/30/22, with no information for 12/2/22.
During an interview on 12/6/22 at 3:29 P.M. the Director of Nursing (DON) said she would expect the staffing hours to be posted daily.
During an interview on 12/3/22 at 3:35 P.M., Human Resources (HR) T said he/she filled out the staffing sheet, took it to the nurse's station, and the nursing staff was supposed to hang it up.
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 store medications in a safe and effective manner. The facility census was 94.
Record review of the facility's Medication Admi...
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Based on observation, interview, and record review, the facility failed to store medications in a safe and effective manner. The facility census was 94.
Record review of the facility's Medication Administration policy, revised 4/7/22, showed:
- Identify the expiration date;
- If medication expired, notify the nurse manager;
- Staff to observe the resident consumption of medications.
1. Observation on 12/2/22 at 8:50 A.M., of a medication pass showed:
- Licensed Practical Nurse (LPN) G provided Resident #44 with an inhaler while the resident sat in the the therapy room;
- While the resident self-administered his/her inhaler, LPN G left the therapy room and closed the therapy room door, went to the medication cart further down the hallway, obtained a blood pressure cuff, and returned to the therapy room;
- LPN G gave the resident his/her oral medication in a pill cup to hold;
- LPN G left the therapy room and closed the therapy room door, went to the medication cart further down the hallway, obtained water for the resident to take his/her medications, and returned;
- LPN G failed to store the medications in a safe and effective manner during the medication pass with the resident.
2. Observation on 12/2/22 at 9:08 A.M., of a medication pass showed:
- LPN G administered Humalog (insulin) by an insulin pen to Resident #60;
- LPN G placed the insulin pen on top of the nurse medication cart and walked away from the cart;
- At 9:21 A.M., LPN G returned to the nurse medication cart and placed Resident #60's Humalog insulin pen back into the cart;
- LPN G left Resident #60's Humalog insulin pen unattended on top of the nurse medication cart for 13 minutes.
3. Observation on 12/2/22 at 11:45 A.M., of the medication cart on E hall showed:
- An open bottle of aspirin (a nonsteroidal anti-inflammatory drug) 81 milligram (mg), with an expiration date of 10/22;
- An open bottle of cetirizine (an antihistamine used to treat allergies) 10 mg, with an expiration date of 9/22.
During an interview on 12/2/22 at 11:48 A.M., LPN G said the aspirin and cetirizine were expired and should not be used. The medications were provided to the nurse manager to discard. LPN G said medications should not be left with residents without supervision.
During an interview on 12/2/22 at 1:45 P.M., the Director of Nursing (DON) said staff were expected to ensure medications in the medication cart were not expired. Staff were also expected to not leave an unattended resident with medications.
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 document accurate immunization status, provide information and educ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document accurate immunization status, provide information and education to each resident or the resident's representative of the influenza vaccine (a vaccine used to protect against influenza), pneumococcal vaccines (a vaccine used to protect against pneumonia bacteria) for two residents (Residents #16 and #26) out of five sampled residents. The facility's census was 94.
Record review of the facility's Patient Immunization policy, revised February 2022, showed:
- Influenza recommend annually for all residents;
- Pneumococcal recommended for resident 65 years and older.
Record review of the facility's Immunization Recommendations for Residents of Long-Term Care Facilities Immunization Manual, undated, showed:
- Influenza recommended annually for all residents;
- Pneumococcal PCV 13 (Pneumococcal conjugate vaccine that protects against 13 types of pneumococcal bacteria) and PPSV23 in persons 65 and older years, unless contraindicated, will be administered according to the facility guidelines when determining the vaccination status.
Record review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, revised on 4/1/22, showed:
- The CDC recommends pneumococcal vaccination for adults [AGE] years old and older and adults 19 through [AGE] years old with certain underlying medical conditions;
- The CDC recommends the administration of one dose of PCV15 or PCV20;
- If PCV20 administered, then the pneumococcal vaccination shall be complete;
- If PCV15 administered, follow with one dose of PPSV23 at least a year apart, with a minimum interval of eight weeks for adults with an immunocompromising condition;
- The CDC recommends those who previously received PPSV23 but not received any other pneumococcal conjugate vaccine, should be administered one dose of PCV15 or PCV20 with a minimum interval of one year apart.
1. Record review of Resident #16's medical record showed:
- An admit date of 8/12/22;
- Over [AGE] years old;
- Diagnoses of Atrial Fibrillation (heart dysrhythmia), hypertension (high blood pressure), and dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning);
- No documentation the facility provided information and education to the resident or the resident's representative regarding the pneumococcal vaccine in 2022.
2. Record review of Resident #26's medical record showed:
- An admit date of 10/7/22;
- Over [AGE] years old;
- Diagnoses include atrial fibrillation, heart failure (when the heart does not pump or fill adequately), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs);
- A Pneumococcal, Prevnar 13, administered on 9/25/15, with no follow up pneumococcal vaccine offered;
- No documentation the facility provided information and education to the resident or the resident's representative of the influenza nor the pneumococcal vaccines.
During an interview on 12/6/22 at 3:20 P.M., the Director of Nursing (DON) said he/she would expect the residents to be offered, educated on, and administered the influenza and pneumococcal vaccines.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. The facility census was 94.
Record review of the facility's Prev...
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Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. The facility census was 94.
Record review of the facility's Preventative Maintenance Program policy, revised November 2017, showed:
- A Preventative Maintenance Program shall be developed and implemented to ensure the provisions of a safe, functional, sanitary and comfortable environment for residents, staff and the public;
- The Maintenance Director will be responsible for developing and maintaining a schedule for maintenance services to ensure that the buildings, grounds, and equipment will be maintained in a safe and operable manner;
- The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance will be required;
- If preventative maintenance will be required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them;
- The Maintenance Director shall develop a calendar to assist with keeping track of all tasks;
- Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years.
Record review of the facility's Cleaning Spills or Splashes of Blood or Body Fluids policy, revised January 2012, showed:
- The purpose of this procedure will be to minimize the danger of environmental contamination and the possible spread of bloodborne infections, including acquired immune deficiency syndrome (AIDS) (a virus that attacks the immune system), human immunodeficiency virus (HIV) (a virus that attacks cells that help the body fight infection) and Hepatitis B (HBV) (a serious liver infection) viruses, to employees and residents while cleaning up spills of blood or body fluid splashes;
- Notify environmental services of spills of blood or body fluids and professional standards of practice.
Observations on 11/29/22 at 3:41 P.M., 11/30/22 at 8:29 A.M., and 12/1/22 at 8:41 A.M. of the B Hall showed:
- A 10 foot (ft.) x three inch (in.) area with exposed sheetrock on the left side of Bed 1 in Room B3;
- A 10 ft. x three in. area with exposed sheetrock on right side of the wall by Bed 1 in Room B8;
- A four ft. x four in. area with exposed sheetrock on the wall by the window of Bed 2 in Room B8;
- A large area of exposed sheetrock on each side of the headboard of Bed 2 in Room B8;
- A two in. x three in. area of exposed sheetrock on the right side of the wall under the light fixture of Bed 1 in Room B9;
- A 30 in. x 30 in. area of peeled paint located behind a decorative eagle print blanket beside Bed 2 by the window in Room B12;
- A large area of dried blood and feces on the wall between Bed 2 and Bed 3 in Room B13.
Observations on 12/2/22 at 8:41 A.M. of the C Hall showed:
- The right side shower room across from central nurse's station with a five in. x 12 in. area of peeled paint on the wall by the paper towel dispenser;
- A one in. x five in. hole located at the top of the cove base on the left side by the bathroom door in Room C3;
- A six in. x one in. hole above the cove base on the left side of the bathroom door in Room C3;
- A five in. x eight in. hole located at the top of the cove base on the right side by the bathroom door in Room C3;
- A four in. x six in. hole located on the right side of the wall with broken sheetrock in Room C13.
Observations on 12/2/22 at 9:21 A.M. of the D Hall showed:
- Three large areas of scraped and peeled paint with exposed sheetrock on the wall above the headboard of Bed 2 by the window in Room D4.
Observations on 11/29/22 at 11:20 A.M. and 11/30/22 at 12:11 P.M. of the kitchen showed:
- A five inch diameter drain cover located in front of the standup freezer with a buildup of a brown colored substance and a large area of the cover deteriorated and missing.
Observation of resident room A6 bathroom on 11/30/22 at 09:50 A.M., showed:
- A small beige colored trashcan located between the commode and sink with dried brown colored splatters all down and across the side that faced the commode;
- The left outside of the commode with multiple dried feces streaks down the side;
- The metal sink faucet base completely covered with white colored calcium buildup;
- The cold and hot sink faucet handles very difficult to turn on and off;
- A three foot length of painted sheetrock tape on right side of door frame was split away from the wall;
- A two foot length of painted sheetrock tape on left side of adjoining bathroom door was split away from the wall.
During an interview on 11/30/22 at 9:50 A.M., the resident in room A6 said that housekeeping comes in and empties the trash but his/her bathroom does not get cleaned very well, and when he/she uses the sink, it is hard to turn the faucet handles on and off, and the white colored buildup has been on there since he/she was admitted to that room about a month ago.
Observation on 11/30/22 at 10:29 A.M., showed:
- Resident #4's right and left wheelchair armrests with exposed filler and cracked vinyl covering;
- Resident #4 sat in his/her wheelchair in his/her room and his/her arm lay on the cracked armrests.
Observation on 11/30/22 at 10:38 A.M., showed:
- The resident's right and left armrest side seams with exposed filler with cracked vinyl covering;
- Resident #46 sat in his/her wheelchair in his/her room and his/her arm lay on the cracked armrests.
Observation on 11/30/22 at 11:43 A.M., showed:
- The resident's right armrest of WC with exposed filler and no vinyl covering;
- Resident #60 sat in his/her wheelchair in his/her room and his/her arm lay on the right armrest.
During an interview on 11/30/22 at 11:49 A.M., Resident #60 said he/she would like someone to look at his/her armrest because it needed to be replaced with a different one.
Record review of September, October and November 2022, Maintenance Request Log showed no current requests for areas of concern documented.
During an interview on 11/30/22 at 9:01 A.M., Hospitality Aid E said if he/she finds a handrail or equipment in need of repair, it was written on the maintenance log to be addressed. The maintenance request log was located outside the maintenance door to write down needed repairs.
During an interview on 11/30/22 at 9:12 A.M., Licensed Practical Nurse (LPN) G said if a repair was needed such as a call light, handrail or wheelchair, he/she wrote it on the maintenance log book located on maintenance door so it could be addressed.
During an interview on 11/30/22 at 9:20 A.M. and 12/02/22 at 12:36 P.M., the Maintenance Supervisor (MS) said staff should be writing down any repairs such as loose handrails and resident equipment on the maintenance request log. He/she did weekly and monthly inspections, but had no documentation to show the environmental rounds were completed on a regular basis, other than the maintenance request log used by staff for repairs and other things needing addressed.
During an interview on 11/30/22 at 3:32 P.M., the Administrator said she would expect staff to write down any necessary repairs or concerns on the maintenance request log located on the outside door of the maintenance department to be addressed in a timely manner. She would expect the Maintenance Supervisor to have documentation of weekly and monthly environmental rounds for review upon request.
During an interview on 12/1/22 at 8:52 A.M., Housekeeper/Laundry Aide H said bodily fluids, such as blood and feces, were to be cleaned by nursing staff.
During an interview on 12/1/22 at 8:58 A.M., Housekeeping/Floor Technician I said nursing staff cleans any areas with feces and wet blood. Once the area was cleaned, someone from the nursing department was supposed to notify housekeeping so the area could be sanitized.
During an interview on 12/1/22 at 9:12 A.M., Certified Nursing Assistant (CNA) F said when there were instances involving fecal matter, blood, or bodily fluids, someone from nursing cleans up the area first, and then notifies housekeeping so the area can be further cleaned and sanitized.
During an interview on 12/1/22 at 9:22 A.M., LPN G, said that blood, fecal matter and bodily fluids should be cleaned by the nursing department first. After the nursing department was done with the initial cleaning, the housekeeping department was notified for further sanitation and cleaning.
During an interview on 12/1/22 at 10:04 P.M., the Administrator said she would expect the nursing department to clean up bodily fluids such as feces or blood first, and not housekeeping. She would expect nursing to notify housekeeping for further cleaning and sanitizing of the area.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of the notice for transfer or discharge to the resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of the notice for transfer or discharge to the resident and or the resident's representative, for six residents (Resident #15, #16, #17, #36, #66 and #70) out of seven sampled residents. The facility's census was 94.
Record review of the Transfer and Discharge Policy, dated 9/22/22, showed:
- Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care
setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities
unless otherwise specified);
- Obtain physician's orders for emergency transfer or discharge, stating the reason the transfer
or discharge shall be necessary on an emergency basis;
- The original copies of the transfer form and the Advance Directive accompany the resident.
Copies will be retained in the medical record;
- Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and
orderly transfer or discharge, in a form and manner that the resident can understand;
- Provide a notice of transfer and the facility's bed hold policy to the resident and representative
as indicated;
- The Social Services Director, or designee, will provide copies of notices for emergency
transfers to the Ombudsman, but they may be sent when practicable, such as in a list of
residents on a monthly basis, as long as the list meets all requirements for content of such
notices.
1. Record review of Resident #15's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 8/31/22;
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party.
2. Record review of Resident #16's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 8/16/22;
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party.
3. Record review of Resident #17's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 8/28/22;
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party.
4. Record review of Resident #36's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 8/9/22 and 9/13/22;
- No documentation of the notification with the reason for the hospital transfer for 8/9/22 and 9/13/22, provided to the resident and/or the resident's responsible party .
5. Record review of Resident #66's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 9/21/22;
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party.
6. Record review of Resident #70's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE];
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party.
During an interview on 12/1/22 at 5:03 P.M., the Administrator said previously they had and used a transfer notification form, but were told by corporate that it wasn't needed and to just fill out the bed hold notification form. They will start providing the transfer form again.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to utilize proper technique during catheter (a tube inserted into the urinary bladder to drain the bladder) care for three resid...
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Based on observation, interview, and record review, the facility failed to utilize proper technique during catheter (a tube inserted into the urinary bladder to drain the bladder) care for three residents (Resident #13, #41, and #66) out of three sampled residents, incontinent care for one resident (Resident # 25) out of two sampled residents, and wound care for one resident (Resident #13) out of a two sampled residents. The facility failed to maintain infection control practices for six residents (Resident #1, #9, #42, #44, #80, and #196 ) out of eight sampled residents during medication administration when facility staff did not wash or sanitize hands or touched medication with bare hands. The facility failed to ensure in the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) by not completing the admission TB screening and/or a yearly risk assessment for symptoms for five residents (Resident #16, #25, #26, #61, and #86) out of five sampled residents. Additionally, the facility failed to update the Infection Prevention Control Policy (IPCP) annually. The facility's census was 94.
Record review of the facility's Hand Hygiene policy, revised 8/16/21, showed:
- Purpose for all staff to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors;
- Hand hygiene means cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR);
- Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;
- The use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves;
- Perform hand hygiene between resident contacts, after handling contaminated objects, before preparing or handling medications, before and after handling clean or soiled dressings, after handling items potentially contaminated with fluids, when moving from a contaminated body site to a clean body site.
Record review of the facility's Catheter Care policy, revised on 7/14/22, showed:
- Residents with indwelling catheters shall receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters in use;
- Gather supplies, perform hand hygiene and don (apply) gloves;
- Wipe from front to back with a disposable wipe or clean cloth moistened with water and perineal cleaner;
- Use a new part of the cloth for each side;
- With a new moistened wipe starting at the urinary opening moving out, wipe the catheter making sure to hold the catheter in place so to not pull on the catheter;
- Dry area with a towel;
- Discard all equipment;
- Perform hand hygiene.
1. Observation of Resident #13 on 11/30/22 at 2:20 P.M., showed:
- Certified Nursing Assistant (CNA) F gathered supplies to provide incontinent care, washed his/her hands, put on gloves and wet two wash cloths;
- CNA F used a cloth and wiped down the perineal area towards the catheter;
- CNA F did not cleanse the catheter itself;
- CNA F with the same gloves, rolled the resident and cleansed the left and right buttocks;
- CNA F did not remove the soiled gloves or wash/sanitize his/her hands between the front and back perineal areas.
2. Observation of Resident #41 on 12/1/22 at 2:20 P.M., showed:
- The resident lay in bed with an indwelling catheter;
- CNA J washed his/her hands, put on gloves and picked up two cleansing wipe cloths with one hand;
- CNA J cleaned down the right and left inner groin crease with the two cleansing wipes;
- CNA J, with the same gloves, picked up a third cleansing wipe, added it to the two previously used wipes, and wiped down the front perineal area and catheter tubing, in one motion;
- CNA J did not wash/sanitize his/her hands, change the soiled gloves, and to use all clean cleansing wipes to clean the front perineal area and the catheter tubing.
During an interview on 12/1/22 at 2:58 P.M., CNA J said incontinent care should consist of wiping each gluteal fold, then cleaning down the perineal area, then the buttocks. Should always clean from the front to the back of the perineal area with a clean cloth. Catheter care should be done by cleaning down the tubing away from the opening.
During an interview on 12/3/22 at 2:10 P.M., the Director of Nursing (DON) said gloves should be changed between dirty and clean care.
During an interview on 12/6/22 at 3:20 P.M., the DON said he/she would expect staff to wash hands between glove changes and change gloves when needed.
3. Observation on 11/29/22 of Resident #66 showed:
- At 12:01 P.M., the resident sat in his/her recliner with the foley catheter bag touching the floor and with no privacy bag covering the catheter bag;
- At 2:53 P.M., the resident sat in his/her recliner with the foley catheter bag touching the floor and with no privacy bag covering the catheter bag;
- No barrier in place between the foley catheter bag and the floor.
During an interview on 12/1/22 at 2:58 P.M., CNA J said the catheter bag should not touch the floor.
During an interview on 12/3/22 at 2:10 P.M., the Director of Nursing (DON) said she would expect privacy bags to be used and catheters to be off of the floor.
4. Record review of the facility's Perineal Care policy, revised on 5/4/22, showed:
- Perform hand hygiene and put on gloves;
- If perineum should be grossly soiled, turn the resident on his/her side, remove any fecal material with toilet paper, then remove and discard. Cleanse the buttocks and anus, front to back, vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. Thoroughly dry;
- Reposition the resident in a supine (lying face up) position;
- Change gloves if soiled and continue with perineal care;
- Apply skin protectants as needed;
- Remove gloves and discard, perform hand hygiene.
Observation of Resident #25 on 12/1/22 at 2:40 P.M., showed:
- CNA J washed hands, put on gloves and wet two wash clothes with peri cleanser;
- CNA J removed fecal material with the soiled brief;
- CNA J cleansed each buttock;
- CNA J did not change gloves;
- CNA J then wiped each groin fold with a clean wash cloth;
- CNA J did not cleanse the perineal area;
- CNA J then pulled the blanket over the resident and touched the bed to move the bed while wearing the same soiled gloves.
During an interview on 12/2/22 at 2:10 P.M., the DON said gloves should be changed between dirty and clean care.
5. Record review of the facility's Wound Treatment Management policy, revised 3/3/22, showed:
- Will promote wound healing of various types of wounds, to provide evidence-based treatments in accordance with current standards of practice and medical providers orders;
- Wound treatments will be provided in accordance with medical provider orders, including the cleansing method, type of dressing, and frequency of dressing change.
Observation of Resident #13 on 11/30/22 at 10:01 A.M., showed:
- Licensed Practical Nurse (LPN) P washed hands, put on gloves, and removed an old dressing to the left extremity;
- LPN P did not change gloves or wash/sanitize hands before applying the ordered ointment to the wound bed with a gloved finger.
During an interview on 11/30/22 at 10:20 A.M., LPN P said gloves should have been changed and hands sanitized between the old dressing and the new dressing. An applicator should have been used to apply ointment to a wound bed.
During an interview on 12/2/22 at 1:15 P.M., the DON said staff should cleanse the wound after removing an old dressing. An applicator should be used to apply ointment to a wound bed.
During an interview on 12/6/22 at 3:20 P.M., the DON said he/she would expect staff to wash hands between glove changes and change gloves when needed.
6. Record review of the facility's Medication Administration policy, revised on 4/7/22, showed:
- Medications will be administered by authorized staff, as ordered and in accordance with professional standards of practice, in a manner to prevent contamination or infection;
- Wash hands prior to administering medication per facility protocol and product;
- Remove medication from source, taking care not to touch medication with bare hand;
- Administer medication as ordered in accordance with manufacturer specifications;
- Observe resident consumption;
- Wash hands using facility protocol and product.
Observation on 12/1/22 at 8:23 A.M., showed:
- Certified Medication Technician (CMT) M administered medications to Resident #9;
- CMT M touched a tablet of Ferrous Sulfate 325 milligram (mg) and Os-Cal Calcium + D3 tablet with his/her bare finger when moving the tablet from the bottle to the medication cup.
Observation on 12/1/22 at 8:33 A.M., showed:
- CMT M administered medications to Resident #1;
- CMT M touched a tablet of Aspirin 81 mg with his/her bare finger when moving the tablet from the medication bottle to the medication cup.
Observation on 12/1/22 at 8:35 A.M., showed:
- CMT M administered medications to Resident #42;
- CMT M did not wash/sanitize hands between Resident #1's and #42's medication administration;
- CMT M touched a tablet of Ferrous Sulfate 325 mg with his/her bare finger when moving the tablet from the medication bottle to the medication cup.
Observation on 12/1/22 at 8:42 A.M., showed:
- CMT M administered medications to Resident #80;
- CMT M touched two Ibuprofen Tablets and a Vitamin C tablet with his/her bare finger when moving them from the bottle to the medication cup.
Observation on 12/1/22 at 8:50 A.M. ,showed:
- LPN G administered medications to Resident #44;
- LPN G touched a tablet of Aspirin 81 mg with his/her finger when moving the tablet from the medication bottle to the medication cup.
Observation on 12/1/22 at 8:59 A.M., showed:
- LPN G administered medications to Resident #196;
- LPN G did not wash/sanitize hands prior to administering the medications.
During an interview on 12/6/22 at 3:20 P.M., the DON said she would expect staff to wash hands between administering medication to residents and not to touch pills with their bare fingers.
7. Record review of the facility's Screening Residents for TB policy, revised July 2013, showed:
- The facility shall screen all residents for tuberculosis infection and disease;
- The facility will screen referrals for admission and readmission for information regarding exposure to, or symptoms of TB and will check results of recent tuberculin skin tests, blood assay, or chest x-rays;
- Any resident without documented negative Tuberculosis Skin Test (TST), Blood assay for Mycobacterium tuberculosis (a bacteria that causes TB) (BAMT), or check x-ray within the previous 12 months, will receive a baseline (two-step) TST or one-step BAMT upon admission. If the first TST is negative, a follow-up TST will be administered one to three weeks after the initial test is read;
- The physician will screen each new admission for possible signs and symptoms of TB;
- The facility will conduct an annual risk assessment to determine TB risk classification;
- If risk classification is low, the facility shall screen residents for TB if they develop symptoms or known exposure. Otherwise, annual screening is not routine;
- If the risk classification is identified as medium risk residents will receive an annual TST, with the exception of known converters (those whose previous skin tests are positive).
Record review of Resident #16's medical record showed:
- An admission date of 8/12/22;
- A TST administered on 10/14/22, with result of negative, no read date and no measurement;
- No second step TST administered.
Record review of Resident #25's medical record showed:
- An admission date of 9/26/15;
- A TST administered on 5/5/21, with result of 0 mm, no read date;
- Screen date for TB on 1/14/21;
- No documentation of a TST or screen for 2022.
Record review of Resident #26's medical record showed:
- An admission date of 10/7/22;
- A TST screening administered on 10/14/22, with status of results pending;
- A TST screening administered on 11/5/22, with results pending;
- A TST screening administered on 11/21/22, with results of 0 millimeters (mm), with no read date.
Record review of Resident #61's medical record showed:
- An admission date of 7/12/21;
- A TST administered on 12/7/21, with result of negative, no read date and no measurement;
- A TST administered on 12/15/21, with results pending;
- A TST administered on 2/7/22, with results of 0 mm with no read date;
- A TST administered on 11/23/22, with a result of negative, no read date and no measurement.
Record review of Resident #86's medical record showed:
- An admission date of 10/14/22;
- TB step one refused with no date;
- TB yearly administered 11/1/22, with status of complete;
- No documentation of a signed refusal or TB results.
During an interview on 12/6/22 at 3:20 P.M., the DON said she would expect the two step TB to be completed upon admission within the recommended timeframe, with a read date, and measurement.
8. Record review of the facility's Infection Prevention and Control Program (IPCP), revised 9/1/21, showed:
- The facility established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections;
- Annual review: The facility will conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures;
- Following review, the infection and prevention control program will be updated as necessary.
Record review of the IPCP showed:
- The IPCP dated 9/1/21;
- No documentation of a review date for 2022 and no signatures.
During an interview on 12/6/22 at 3:20 P.M., the Administrator said the IPCP should be reviewed annually and signed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure the handrails on the A, C, D and E Halls were properly maintained. This deficient practice had the potential to affect ...
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Based on observation, interview and record review, the facility failed to ensure the handrails on the A, C, D and E Halls were properly maintained. This deficient practice had the potential to affect all residents on these halls. The facility census was 94.
Record review of the facility's Preventative Maintenance Program policy, revised November 2017, showed:
- A Preventative Maintenance Program shall be developed and implemented to ensure the provisions of a safe, functional, sanitary and comfortable environment for residents, staff and the public;
- The Maintenance Director will be responsible for developing and maintaining a schedule for maintenance services to ensure that the buildings, grounds, and equipment will be maintained in a safe and operable manner;
- The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance should be required;
- If preventative maintenance should be required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them;
- The Maintenance Director shall develop a calendar to assist with keeping track of all tasks;
- Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years.
Observations on 11/29/22 at 2:30 P.M., 11/30/22 at 12:18 P.M., and 12/1/22 at 8:47 A.M. of the A Hall showed:
- A missing end piece of the handrail located on the right side of the door by Room A8;
- A missing end piece of the handrail located on the right side of the door by Room A11;
- A one foot section of handrail came out of the drywall when grabbed with minimal force located between the beauty shop and the mechanical room.
Observation on 12/2/22 at 9:34 A.M. of the C Hall showed:
- A missing end piece of the handrail located on the left side of the door by Room C2.
Observation on 12/2/22 at 9:47 A.M. of the D Hall showed:
- A missing end piece of the handrail located on the right side of Room D2.
Observation on 12/2/22 at 9:54 A.M. of the E Hall showed:
- A missing end piece of the handrail located on the left side of the exit door leading to the outside resident smoke area;
- A missing end piece of the handrail located on the right side of the exit door leading to the outside resident smoke area.
Record review of September, October and November 2022 Maintenance Request Log showed:
- No documentation of current requests for handrail repairs.
During an interview on 11/30/22 at 9:01 A.M., Hospitality Aid E said if he/she finds a handrail or any equipment in need of repair, it was written on the maintenance log to be addressed. The maintenance request log was located outside the maintenance door to write down needed repairs.
During an interview on 11/30/22 at 9:12 A.M., Licensed Practical Nurse (LPN) G said if a repair was needed such as a call light, handrail or wheelchair, he/she would write it on the maintenance log book located on the maintenance door so it could be addressed.
During an interview on 11/30/22 at 9:20 A.M. and 12/2/22 at 12:36 P.M., the Maintenance Supervisor (MS) said staff should be writing down any repairs such as loose handrails and resident equipment on the maintenance request log. He/she does weekly and monthly inspections, but he/she did not have any documentation to show the environmental rounds were completed on a regular basis. The only documentation he/she had was the maintenance request log used by staff for repairs and other things that needed to be addressed.
During an interview on 11/30/22 at 3:32 P.M., the Administrator said she would expect staff to write down any necessary repairs or concerns on the maintenance request log which was located on the outside door of the maintenance department. She would expect the necessary repairs to be addressed in a timely manner, and she would expect the Maintenance Supervisor to have documentation of the weekly and monthly environmental rounds for review upon request.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This ...
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Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This potentially affected all residents. The facility census was 94.
Record review of the facility's General Sanitation of the Kitchen policy, revised July 2019, showed:
- Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule;
- Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule;
- Tasks will be assigned to be the responsibility of specific positions;
- Frequency of cleaning for each task will be defined;
- Employees will be trained on how to perform cleaning tasks;
- On the cleaning schedule, employees will initial and date tasks when completed.
1. Observations of the kitchen on 11/29/22 at 11:20 A.M. and 12:11 P.M., showed:
- A black griddle on top of the stove with a buildup of a hard black crusty substance;
- Two black griddles on the bottom shelf by the stove with a buildup of a hard black crusty substance;
- Carbon buildup on the front panel of the Smart Team boilerless steamer;
- A powdery substance on top of the Smart Team boilerless steamer;
- Dirt and debris under the Smart Team boilerless steamer;
- A food thermometer lay on the floor under the Smart Team boilerless steamer;
- Dirt and debris buildup on top of the Vulcan stove;
- The dish machine with carbon buildup and debris on the top, the sides, and the bottom;
- The trash compacter with a buildup of debris and food particles;
- A loaf of bread on the counter, not labeled or dated when opened;
- A 160 count of sliced cheese on the counter, not labeled or dated when opened;
- A jar of grape jelly on a cart, not dated when opened;
- A gallon of barbeque sauce on a cart, not dated when opened;
- Three totes and one ziploc bag contained a variety of cereals by the mealtime serving window, not labeled or dated;
- A bag of hamburger buns on the counter, not labeled or dated when opened;
- A bag of instant nonfat dry milk unsealed in the dry goods storage room, not dated when opened;
- A box of Ready Care thickened apple juice on the shelf in the storage room, not dated when opened.
2. Observations of the kitchen on 11/30/22 at 8:17 A.M. and 11/30/22 at 11:09 A.M., showed:
- A loaf of bread on the counter, not labeled or dated when opened;
- The steam table with a buildup of grime and stains on the front panel by the turn knobs;
- The bottom shelf under the steam table with a buildup of grime, stains and debris;
- Two bags of tater tots in the freezer, not labeled or dated;
- A bag of fish sticks in the freezer, not labeled or dated;
- A 160 count of sliced cheese on the counter uncovered, not labeled or dated when opened.
During an interview on 11/30/22 at 11:16 A.M., [NAME] A said he/she cleaned as much as possible during the shift, but did not have enough time. He/she did not document any cleaning tasks completed on any type of form. The kitchen should be cleaned regularly, including the equipment and the counters. The kitchen foods should have a label and dated. The kitchen cookware should be free of buildup and grime.
During an interview on 11/30/22 at 11:20 A.M., Kitchen Aid B said he/she cleaned as much as time allows during the shift. The kitchen area should be cleaned on a regular basis, but did not have a form to document the tasks upon completion. He/she labeled and dated the food and it should be done by the staff working on the day of the truck delivery.
During an interview on 11/30/22 at 11:23 A.M., [NAME] C said he/she cleans the equipment, the floors, the counters, and the stove when time allowed. He/she did not have a checklist form to show what tasks were completed in the kitchen. There were some kitchen cookware in need of replacement and he/she thought the dietary manager was aware since he/she did the ordering. The food in the kitchen should have a label and be dated.
During an interview on 11/30/22 at 11:26 A.M., Dish Aid D said he/she cleaned the dishwashing area during the shift and did not know of a cleaning checklist to complete. He/she did not know for sure who labeled or dated the food in the kitchen, but thought it was the dietary manager.
During an interview on 11/29/22 at 12:45 P.M. and 11/30/22 at 8:37 A.M., the Dietary Manager (DM) said he/she did not know the kitchen cleaning checklist documentation was supposed to be kept on file and threw all of the copies away. He/she would expect all foods to have a label and be dated. He/she would expect the kitchen to have cookware free of buildup and grime. He/she would expect the kitchen equipment to be free of buildup of carbon, grime and debris.
During an interview on 11/30/22 at 11:37 A.M., the Senior Regional Dietary Manager said he/she would expect the kitchen staff to label and date all food in the kitchen, the cookware to be free of buildup and grime, the equipment be free of carbon buildup and grime, and the documentation of the kitchen cleaning tasks scheduled and completed on a regular basis for an audit review.
During an interview on 12/01/22 at 9:33 A.M., the Administrator said she would expect kitchen staff to have all food labeled and dated upon delivery, cookware to be free of buildup and grime, equipment to be free of carbon buildup and grime, and documentation of the kitchen cleaning scheduled and kitchen tasks completed on a regular basis.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $42,770 in fines, Payment denial on record. Review inspection reports carefully.
- • 54 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $42,770 in fines. Higher than 94% of Missouri facilities, suggesting repeated compliance issues.
- • Grade F (18/100). Below average facility with significant concerns.
Bottom line: Trust Score of 18/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Arbor View Nursing And Rehabilitation's CMS Rating?
CMS assigns ARBOR VIEW NURSING AND REHABILITATION an overall rating of 1 out of 5 stars, which is considered much 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 Arbor View Nursing And Rehabilitation Staffed?
CMS rates ARBOR VIEW NURSING AND REHABILITATION's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 70%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Arbor View Nursing And Rehabilitation?
State health inspectors documented 54 deficiencies at ARBOR VIEW NURSING AND REHABILITATION during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 50 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Arbor View Nursing And Rehabilitation?
ARBOR VIEW NURSING AND REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by VERTICAL HEALTH SERVICES, a chain that manages multiple nursing homes. With 150 certified beds and approximately 83 residents (about 55% occupancy), it is a mid-sized facility located in CEDAR HILL, Missouri.
How Does Arbor View Nursing And Rehabilitation Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, ARBOR VIEW NURSING AND REHABILITATION's overall rating (1 stars) is below the state average of 2.5, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Arbor View Nursing And 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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Arbor View Nursing And Rehabilitation Safe?
Based on CMS inspection data, ARBOR VIEW NURSING AND REHABILITATION has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-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 Arbor View Nursing And Rehabilitation Stick Around?
Staff turnover at ARBOR VIEW NURSING AND REHABILITATION is high. At 56%, the facility is 10 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 70%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Arbor View Nursing And Rehabilitation Ever Fined?
ARBOR VIEW NURSING AND REHABILITATION has been fined $42,770 across 6 penalty actions. The Missouri average is $33,507. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Arbor View Nursing And Rehabilitation on Any Federal Watch List?
ARBOR VIEW NURSING AND 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.