MASON POINTE CARE CENTER
Non profit - Corporation
127 Beds
EVERTRUE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
71/100
#35 of 479 in MO
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Mason Pointe Care Center in Chesterfield, Missouri, has a Trust Grade of B, indicating it is a good choice for families considering nursing home options. It ranks #35 out of 479 facilities in Missouri, placing it in the top half, and #7 out of 69 in St. Louis County, meaning there are only six local options better than this facility. The facility's performance has been stable, with one issue reported in both 2023 and 2024, and it has a solid staffing rating of 4 out of 5 stars, with a turnover rate of 45%, which is below the state average. However, families should be aware of a critical incident involving a staff member committing sexual acts against a resident, which is concerning and highlights serious safety issues. On a positive note, the facility has more RN coverage than 90% of Missouri facilities, ensuring that trained professionals are present to monitor residents and catch potential problems.
- Trust Score
- B
- In Missouri
- #35/479
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ⚠ Watch
- 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $19,460 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 49 minutes of Registered Nurse (RN) attention daily — more than average for Missouri. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 18 deficiencies on record. Higher than average. Multiple issues found across inspections.
71/100
Top 7%
Review needed
1 → 1 violations
★★★★★
5.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2023: 1 issues
2024: 1 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 45%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Federal Fines: $19,460
Below median ($33,413)
Minor penalties assessed
Chain: EVERTRUE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 18 deficiencies on record
1 life-threatening
Aug 2024
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that 1.) one of two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that 1.) one of two treatment carts (A3 skilled unit) was locked and secured. This failure created the risk of unauthorized access to medications and supplies by residents and staff, and 2.) failed to ensure expired medical supplies; including urinary catheters, intravenous (IV) catheters, and syringes; were removed from one of two medication rooms (M3 skilled unit). This failure created the risk of less effective medical supplies being used for residents.
Findings include:
1. Review of R169's Face Sheet, located in the resident's electronic medical records (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia, and manic-depressive disorder.
Review of R169's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/24 and located in the resident's EMR under the MDS Assessments tab, indicated R169 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. The MDS indicated the resident had periods of verbally and physically aggressive behaviors which had gotten worse since the last assessment.
On 08/20/24 at 2:02 PM, an unlocked treatment cart on the A3 skilled unit was observed. The treatment cart was located across from the nurses' station, and no nursing staff were present in the area. The top drawer of the treatment cart was observed to contain Eliquis (an anticoagulant) 2.5 milligrams (mg), famotidine (an antihistamine) 20 mg, and vitamin C 500 mg. The bottom drawer contained two bottles of guaifenesin syrup (an expectorant). The other drawers on the treatment cart contained various wound supplies.
During the observation of the treatment cart on 08/20/24 at 2:02 PM through 2:20 PM, a total of 18 minutes, Resident (R) 169 was observed sitting in a wheelchair, propelling himself around the nurses' station and near the treatment cart. At 2:20 PM, Licensed Practical Nurse (LPN) 1 returned to the nurses' station and locked the treatment cart.
During an interview on 08/20/24 at 2:21 PM, LPN1 stated she was the last person to use the treatment cart and left it unlocked. LPN1 verified the treatment cart contained the Eliquis, famotidine, guaifenesin cough syrup medication, and wound supplies. LPN1 stated it was hazardous to leave the treatment cart unlocked. LPN1 stated that even though R169 had a BIMS score of 13, the resident exhibited periods of confusion and wandering behaviors.
2. During an observation on 8/21/24 at 9:38 AM, the following was observed in the medication room on the M3 skilled unit:
One of one Coude catheter (a urinary catheter with a slightly curved or angled tip) 16 French, with an expiration date of 01/28/24.
One of one [NAME] Introcan Safety Intravenous (IV) catheter 20 gauge (ga), with an expiration date of 08/01/24.
One of one [NAME] Introcan Safety IV catheter 22 ga x 1 inch, with an expiration date of 08/01/24.
Two of two [NAME] IV catheters 22 ga x 1-inch, both with an expiration date of 08/15/24.
Four of four [NAME] IV catheters 24 ga x 0.75 inch, all with an expiration date of 08/08/24.
12 of 12 [NAME] 10 cubic centimeter (cc) syringes with luer lock tips, all with an expiration date of 03/01/23.
During an interview on 08/21/24 at 9:35 AM, Certified Medication Technician (CMT) 1 revealed the pharmacy consultant usually checked the medication carts and medication rooms for expired medications and supplies monthly; however, the nurses tried to check it more frequently.
During an interview on 08/21/24 at 9:45 AM, LPN1 stated the unit manager was responsible for checking the medication room for expired medications and supplies, and the MDS nurse was responsible for checking the medication carts for expired medications.
During an interview on 08/22/24 at 11:15 AM, the Assistant Director of Nursing (ADON) stated that LPN1 had made her aware of the treatment cart on A3 skilled unit being left unlocked. The ADON stated it was the expectation that treatment and medication carts were to be always locked when not in use. The ADON stated that although R169 appeared to be cognitively intact at times, the resident had periods of confusion and poor decision-making capabilities. The ADON stated it was a hazard to leave the treatment cart unlocked, especially with R169 in the areas. The ADON stated that she was made aware of the expired supplies in the medication room on the M3 skilled unit. The ADON stated that the pharmacy consultant inspected the medication rooms and carts for expired medications and supplies; however, she and the unit managers should inspect the medication rooms in between the pharmacy consultant visits.
Review of the facility's policy titled, Labeling and Storage of Medications, dated 01/31/24, revealed, . The community will not use discontinued, outdated, or deteriorated medications . Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications shall be locked when not in use and trays or carts that transport such items should not be left unattended if open or otherwise potentially available to others .
Apr 2023
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on observation, interview and record review, the facility failed to protect one resident's right to be free from sexual abuse when a staff member, Nurse A, performed sexual acts on the resident ...
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Based on observation, interview and record review, the facility failed to protect one resident's right to be free from sexual abuse when a staff member, Nurse A, performed sexual acts on the resident multiple times (Resident #1). On 3/28/23, Nurse A asked the resident if the resident ever had oral sex, and performed oral sex until the resident asked Nurse A to stop. Nurse A stopped and manually touched the resident until the resident ejaculated. The sample was 7. The census was 106.
The Administrator was notified on 04/13/23, at 4:26 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 03/28/23. On 03/30/23, the Administrator became aware. Nurse A was terminated and inservicing for all staff was conducted. A trauma assessment was completed on the resident. All residents on Nurse A's assignment were interviewed with no further concerns noted. The IJ was corrected on 3/31/23.
Review of the facility's Abuse/Neglect Prevention and Response policy, revised 10/23/17, showed:
-Residents and clients of Lutheran Senior Services (LSS) campuses and programs will live and be served in an environment which promotes dignity, respect and strives to be free from abuse, neglect and exploitation. Allegations of potential or actual abuse, neglect or exploitation will be immediately reported to the appropriate leadership and government agency, the resident protected and the allegation investigated;
-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish as well as the deprivation of goods or services necessary to attain or maintain physical, mental and psychosocial well-being;
-Sexual Abuse is defined as, but not limited to, sexual harassment, sexual coercion and sexual assault;
-To ensure an environment that encourages respectful and dignified treatment of residents, LSS will staff its facilities and programs with sufficient numbers and types of personnel so residents'/clients' needs will be met. LSS will provide proper supervision to ensure staff are providing care in an appropriate manner and staff assess, care plan and monitor the care of all residents. LSS will ensure staff pay special attention to those residents and clients with needs or behaviors which may make them more likely targets for abuse or neglect;
-Staff, residents and families are told it is their responsibility to report situations they consider abusive or negligent. During training, staff members are informed of how to identify situations which could be either isolated incidents of abuse or patterns of the same;
-Any time an allegation of abuse or neglect involves an employee, that individual will be suspended from duty until an investigation is completed. Based on the outcome of the investigation, the employee will return to work (with or without pay) or be terminated;
-Staff shall immediately see to the safety of an alleged resident victim upon an allegation of abuse. This includes, but is not limited to, removing accused staff from contact with all residents, providing necessary medical treatment to the alleged resident victim, preserving the anonymity of the alleged resident victim, regular monitoring of the alleged resident victim and all other actions deemed necessary by the circumstances.
Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/29/23, showed:
-Exhibited unclear speech;
-Understood and understands others;
-Cognitively intact;
-Exhibited no behaviors;
-Total care with activities of daily living (ADLs);
-Diagnoses included spastic hemiplegic cerebral palsy (a type of cerebral palsy that occurs when the condition of muscle stiffness impacts one full side of the body), dysarthria (motor speech disorder that makes it difficult to form and pronounce words), dysphagia (language disorder), anxiety disorder and major depressive disorder.
Review of the resident's care plan, dated 6/12/17, showed:
-Problem: The resident's quality of life was better when the resident was able to do things most important to the resident;
-Interventions: The resident would be assisted to masturbate, no longer than two hours at a time, twice per day, as staff availability permits, by placing a privacy sign on the resident's door. During these time periods, staff would place the resident in the resident's wheelchair as the resident's wish and allow privacy. The resident would be assisted by staff the resident is comfortable with.
Review of a police investigative report, showed:
-On 3/30/23 at 7:53 P.M., police responded to a location for a report of sexual assault. The resident was attending an outing at the location and informed the Chief Program Officer (CPO) the resident was sexually assaulted by a nurse at the nursing facility the resident resides at. The CPO said the resident came to him/her crying and said on 3/26/23, at approximately 9:00 P.M.-9:30 P.M., the night nurse put the resident to bed and put the nurse's mouth on the resident's penis. The resident described the nurse, knew the nurse by first name, and said the nurse only worked nights. With the assistance of the CPO, the resident confirmed all of this information to the police officer. The resident said the resident would not be comfortable staying at the facility if the nurse was there. The resident typed out a statement on the resident's computer about the incident and wanted to retrieve it. The CPO contacted the resident's responsible party and he/she contacted the facility Administrator. The Administrator said the nurse was not at the facility and the resident agreed to return to the facility. The police officer accompanied the resident to the resident's room and retrieved the resident's typed statement. The statement indicated the incident occurred on 3/27/23. The time stamp on the word document showed it was created on 3/30/23. The suspect was identified as Nurse A.
Review of Resident #1's typed statement, showed the night nurse, (Nurse A), Monday night, sucked my private area. It happened so fast I did not know what was happening. Now I am very afraid of the nurse. The nurse acts funny towards me. I think the nurse thinks I am going to tell on the nurse. I am very afraid of the nurse.
Review of the Director of Clinical Compliance (DOCC) F's typed statement, showed:
-On 3/31/23 at 4:32 P.M., Nurse A returned his/her call. The DOCC asked Nurse A if the nurse had sexual contact with any other residents and the nurse said, No, I was just helping (Resident #1). I asked (the resident) if (the resident) ever had a blow job and (the resident) said no. So I gave (the resident) one. I went up and down three times and (the resident) said stop, so I did. I finished with my hand. Nurse A was informed the nurse was terminated.
Review of the facility's investigation dated 3/31/23, showed:
-The resident reported the incident on 3/30/23. The resident will be seen by a licensed clinical social worker (LCSW) psychotherapist, assessed for trauma and evaluated on 4/1/23. The resident feels comfortable and safe at facility;
-The facility made numerous attempts to contact Nurse A on 3/30/23, but was unable to make contact until 3/31 at which time the nurse admitted to performing oral sex on the resident. The nurse said it occurred on 3/28/23. Nurse A said it only occurred with the resident. The facility notified the police of this new information and Nurse A was terminated. Nurse A was also notified the nurse was not allowed on the facility's premises;
-Based upon the admission by Nurse A, the facility substantiated the allegation the nurse performed oral sex on the resident and no other residents were affected.
Review of the facility's night shift staffing schedule on 3/28/23, showed Nurse A worked from 7:00 P.M. to 7:00 A.M.
Review of the interview with the resident and Administrator on 3/31/23 at 10:00 A. M., showed:
During his private time, Nurse A entered his room. Nurse A put the resident in bed as he typically does. Nurse A put his mouth on the resident's penis. The resident asked Nurse A to stop and he did.
Observation and interview on 4/7/23 at 1:54 P.M., showed the resident sat in the wheelchair with a communication device attached. The resident said the incident happened on 3/26/23. The resident said, I'm bad. The resident said he was seated in the wheelchair at the resident's computer, watching porn and Nurse A entered the resident's room. Nurse A asked the resident if the resident has ever had a blow job. The resident said no. Nurse A got on the nurse's knees and put the nurse's mouth on the resident's penis. The resident asked Nurse A to stop and the nurse did. The resident asked Nurse A to use the nurse's hand to help the resident ejaculate and the nurse did. This was the first time Nurse A put the nurse's mouth on the resident's penis. The resident asked Nurse A to use the nurse's hand to help the resident ejaculate because the resident could not do it. Nurse A has used the nurse's hand to help the resident ejaculate several times in the past. The resident did not know how many times it happened. The resident did not report it to anyone. The resident said, I feel safe and I am okay. (Nurse A) was just trying to help me.
During an interview on 4/11/23 at 3:05 P.M., the police officer said he/she interviewed the resident on 4/11/23 and the resident said Nurse A has helped the resident masturbate before.
During an interview on 4/7/23 at 11:20 A.M., the Administrator said she received a call on 3/30/23 at 7:45 P.M. from the resident. The resident was on a church outing and disclosed that Nurse A put the nurse's mouth on the resident's penis. Nurse A was not in the building and the resident agreed to return to the facility. The resident said the incident occurred on 3/26/23. Nurse A did not work on 3/26/23 and 3/27/23. She asked the resident if the incident occurred during the resident's private time and the resident said yes. She informed the resident this was a criminal investigation. DOCC E spoke to Nurse A and the nurse said the incident happened on the night shift on 3/28/23. Nurse A was terminated on 3/31/23. The police arrived at the facility on 3/31/23 and interviewed the resident. The resident told the police officer the resident asked Nurse A to stop the blow job and the nurse did. The resident said the blow job lasted 30 seconds. The resident asked Nurse A to finish with the nurse's hand and the nurse did. The hand job lasted approximately one minute. The resident said Nurse A has helped the resident masturbate before and the resident never reported it.
During an interview on 4/7/23 at 1:00 P.M., DOCC E said she called Nurse A when she found out about the incident and the nurse did not answer. The nurse returned her call two days later. She asked the nurse if the nurse performed oral sex on the resident and the nurse said, Yes I did. I was helping the resident out, because the resident has never had a blow job. The nurse said the nurse did not have any sexual contact with other residents.
During an interview on 4/10/23 at 10:18 A.M., Nurse B said he/she has worked at the facility for three years. He/She gave Nurse A report on 3/28/23 around 7:00 P.M. He/She did not notice anything unusual with the resident. Nurse B is aware of the intervention in the resident's care plan to be allowed privacy to masturbate. He/She did not receive education on what set up meant. Nurse B said the resident told him/her Nurse A has helped the resident set up in the past. He/She did not say how Nurse A helped the resident set up. The resident only wanted Nurse A, Nurse B and Certified Nurse Assistant (CNA) C to help the resident set up for masturbation.
During an interview on 4/11/23 at 12:19 P.M., CNA C said he/she is the resident's primary caregiver. The resident has asked him/her to help set up for masturbation once.
Review of the resident's behavior log, dated 4/1/23 to 4/14/23, showed no documented behaviors.
Review of the resident's psychotherapy evaluation dated 4/1/23, showed:
-The therapist was informed of incident with resident and staff member;
-Staff requested trauma assessment. He/She utilized the clinician administered post-traumatic stress disorder (PTSD) scale (CAPS-five, structured interview used to assess PTSD symptoms over the past week) for guidance;
-The resident was alert and oriented times three (person, place and time) and showed no visible signs of distress;
-The resident denied any distress, physically or psychologically;
-The resident did not qualify for PTSD diagnosis, per the CAPS-five;
-The resident admitted to mild to moderate feelings of sadness;
-The resident expressed some worry, specifically guilt feelings and worry about staff member involved;
-The resident has a history of guilt feelings around sexual issues;
-Plan: Follow-up over next month to monitor for changes in behaviors and mood. Nurse Supervisor aware of need for monitoring resident status. Increase visits from one time per week to two times per week for one month.
Review of the resident's social service note, dated 4/3/23, showed the resident said the resident forgives Nurse A. The resident said Nurse A was only trying to help the resident. The Social Services Coordinator (SSC) informed the resident he/she would be meeting with him/her weekly. The resident's mood was good and no signs of tearfulness or being upset were noted.
Review of the resident's physician progress note, dated 4/4/23, showed:
-The physician was informed of abuse by staff on 3/31/23;
-The resident said the resident is okay;
-The facility was providing psychological therapy assistance;
-The resident will be monitored for behavioral changes.
Review of the resident's psychotherapy evaluation, dated 4/5/23, showed:
-The resident did not exhibit any signs of trauma;
-Ongoing follow-up/assessment/monitoring for mood/behavioral changes.
Review of the resident's social service notes, showed:
-On 4/7/23, the resident stayed in bed. The resident said the resident was not sad and appeared to be in good spirits;
-On 4/11/23, the resident said the resident was doing okay and did not voice any concerns;
-On 4/13/23, the resident said the resident felt down and bad at times, because the resident did not know why Nurse A did it. The resident said talking to the psychotherapist is helping the resident.
During an interview on 4/13/23, the SSC said he/she met with the resident on 4/3/23. The resident said Nurse A was trying to help the resident and the resident forgave the nurse. The resident did not elaborate. He/She has met with the resident twice per week since 4/3/23. The resident was happy and did not voice any concerns. The resident has not expressed any guilt or fear.
During interviews on 4/10/23 at 9:48 A.M. and 4/13/23 at 2:33 P.M., DOCC E said staff were supposed to put the resident in the resident's wheelchair and place the resident in front of the resident's computer to watch porn, then the resident would attempt to masturbate. The resident only wanted CNA C, Nurse A, and Nurse B to help the resident set up. Nurse A helped the resident set up in the evenings. Staff were not trained on how to help the resident set up. There were parameters in place about how much help staff would provide. Staff were to provide privacy and accessibility only.
During an interview on 4/7/23 at 11:20 A.M., the Administrator said the resident is concerned about Nurse A and said the resident loves Nurse A. The resident says he/she does not want to watch porn or masturbate anymore.
MO00216283
MO00216284
Jun 2019
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure the resident's right to self-administer medications is supported, only if the interdisciplinary team has determined tha...
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Based on observation, interview and record review, the facility failed to ensure the resident's right to self-administer medications is supported, only if the interdisciplinary team has determined that this practice is clinically appropriate, for two residents observed to self-administer medications (Residents #45 and #11). The census was 205 with 140 in certified beds.
Review of the facility's Policy and Procedure for Administering Medication, dated 1/25/17, and reviewed on 9/25/18, showed:
-Policy Statement: Medication shall be administered in a safe and timely manner and as prescribed. The community shall provide residents with necessary medication(s) when they leave the community temporarily;
-Residents may self-administer their own medications only if the physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that the resident has the decision-making capacity to do so safely.
1. Review of Resident #45's electronic physician order sheet (ePOS), showed:
-Diagnoses included High blood pressure, heart disease, chronic kidney disease and osteoarthritis;
-An order dated 12/12/18, to administer Benefiber (a laxative) Sugar free 3 grams/3.8 gram powder, one teaspoon by mouth three times a day for constipation;
-An order dated 2/20/19, to administer Tylenol extra strength (pain medication) 500 milligram (mg) one caplet by mouth twice a day;
-No order to self-administer any medications.
Observation on 6/6/19 at 12:03 P.M., showed the resident sat in the division dining room. Staff served his/her lunch. Certified Medication Tech (CMT) E poured up the Benefiber in a medication cup and the Tylenol extra strength into another medication cup. He/she set them down in front of the resident and walked away from the resident without ensuring the resident took the medications. CMT E went to the sink, washed his/her hands, walked to the medication cart and started to pour up another resident's medications. The resident placed both of the medication cups with the medications in front of his/her plate. At 12:21 P.M., the resident poured the Benefiber powder on top of his/her bowl of broccoli cheese soup and self-administered the Tylenol extra strength. At 12:26 P.M., the resident had eaten the entire bowl of soup with the Benefiber.
2. Review of Resident #11's ePOS, showed:
-Diagnoses included osteoarthritis, high blood pressure and heart burn;
-An order dated 12/12/18, to administer multivitamin one cap by mouth once a day;
-No order to self-administer any medications.
Observation on 6/6/19 at 12:06 P.M., showed the resident sat in the division dining room. Staff served his/her lunch. CMT E poured up the multivitamin into a plastic medication cup, set it down in front of the resident and walked away from the resident without ensuring the resident took the medication. CMT E went to the sink, washed his/her hands, walked to the medication cart and started to pour up another resident's medications. The resident took the medication cup with the multivitamin and placed it at the top of his/her plate, then cut up and started to eat his/her hamburger. At 12:09 P.M., the resident picked up the medication cup and self-administered the multivitamin.
3. During an interview on 6/7/19 at 10:15 A.M., the Director of Nursing said neither of the residents have orders to self-administer any medications. It would never be appropriate to leave medications with a resident. She would expect staff to stay and ensure the medications were taken since the residents cannot be left unsupervised for consumption of medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to maintain all survey reports, certifications and complaint investigations made during the three preceding years and any plan of correction in ...
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Based on observation and interview, the facility failed to maintain all survey reports, certifications and complaint investigations made during the three preceding years and any plan of correction in effect with respect to the facility. The census was 205 with 140 residents in certified beds.
Observations on 6/5/19 at 8:10 A.M., on 6/6/19 at 6:30 A.M., on 6/7/19 at 1:00 P.M., on 6/10/19 at 11:42 A.M. and on 6/11/19 at 1:40 P.M., showed a sign posted at the front entrance of the Arborview building, Facility state survey results are available for viewing. A binder containing results is located at the Arborview reception desk. Observation of the Arborview reception desk, showed no state survey results binder available for viewing.
During an interview on 6/10/19 at 11:42 A.M., when questioned about the state survey results binder, Receptionist A walked back into another office behind the reception desk, brought out the binder and said the binder is always kept in the room behind the reception desk and visitors, residents and staff would have to ask the receptionist to see the binder.
Observation on 6/10/19 at 12:05 P.M., showed a sign posted on the wall behind the reception desk at the front entrance of the Hillside building, Facility State Survey results are available for viewing. Binder is located on wall near the Hillside reception desk. Observation of the reception area, showed no facility employee at the Hillside reception desk and no state survey results binder found.
During an interview on 6/10/19 at 1:46 P.M., Receptionist A said they only have one survey result binder for the certified section of the building and it is located at the Arborview reception desk.
During an interview on 6/11/19 at 1:20 P.M., the administrator verified the facility had only one state survey result binder, the binder is kept in the room behind the reception desk on Arborview and said anyone wishing to look at the binder had to ask.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy for abuse and neglect by failing to report an i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy for abuse and neglect by failing to report an incident of potential resident to resident abuse to the State Survey Agency when a resident slapped another resident (Residents #14 and #62). The census was 205 with 140 residents in certified beds.
Review of the Centers for Medicare and Medicaid services (CMS) State Operations Provider Certification, showed §483.12 Freedom from Abuse, Neglect, and Exploitation:
-The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation;
-Definitions: Abuse, is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish;
-Guidance: Resident to Resident Abuse of Any Type: A resident to resident altercation should be reviewed as a potential situation of abuse. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby;
-In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedure.
Review of the facility's abuse/neglect prevention and response policy, revised 10/23/17, showed the following:
-Policy statement: Residents and clients of the facility campuses and programs will live and be served in an environment that promotes dignity, respect and strives to be free from abuse, neglect and exploitation. Allegations of potential or actual abuse, neglect or exploitation will be immediately reported to the appropriate leadership and government agency/agencies, the resident protected and the allegation investigated;
-Timeframe to report to authorities: Administrator or Administrator's designee, shall timely report allegation to appropriate authorities in accordance with applicable state law. The authorities will also be timely notified of any changes in condition of the alleged resident victim. Allegations of abuse, neglect, exploitation or mistreatment, misappropriation of property and serious injuries of unknown origins will be immediately reported to appropriate authorities but no later than 2 hours after the basis of the allegation occurred. All other reportable events will be reported to the authorities within 24 hours.
1. Review of Resident #14's physician's note, dated 5/3/19, showed the following:
-History of the present illness: Resident #14 admitted to the facility for rehab. He/she has a history of Alzheimer dementia, and anxiety. He/she has been a resident of an assisted living community from 2016 until March 2018, at which time it appears he/she had moved to the Memory Care Unit due to advancing dementia. He/she was admitted to the hospital on [DATE] for aggressive behavior. Apparently, for about a month, he/she had been noted to have anxiety, and increasingly aggressive behavior. He/she would at times hit residents and staff, and be quite aggressive. He/she also was noted to have inappropriate kissing and touching towards others on the unit. He/she was followed by Psychiatry, and was managed on Depakote (anti-seizure medication also used to treat some psychiatric conditions), Abilify (depression medication) and trazodone (sedative and depression medication). Due to worsening aggressive behavior he/she was transported to the hospital on 2/1/19, it was noted that in route, he/she did strike an emergency medical technician (EMT) trying to assist. On admission, lab work obtained were unremarkable. He/she did require two doses of Haldol (antipsychotic medication) 5 milligrams (mg) intramuscular (into the muscle) in the emergency room due to combativeness, climbing over the side rails, attempting to grab staff, and kicking at staff. He/she was admitted to behavioral health, and the regimen of Abilify, Depakote and trazodone was continued, and Remeron (antidepressant) was added at bedtime, and trazodone was added as needed at bedtime for insomnia. On the unit, he/she was noted to have anxiety, restlessness, fidgetiness, blunted affect, and was very confused. He/she was pacing and wandered, but was redirectable. His/her behavior issues improved, and he/she was discharged back to the a facility's memory care on 2/12/19, at that time, on Remeron 15 mg at bedtime, Abilify 5 mg daily, Depakote 375 mg twice daily, and trazodone 25 mg three times daily. Unfortunately, he/she quickly required readmission to the hospital on 02/14 for very similar behaviors. He/she was noted trying to pull a resident out of a chair, pulled the resident's hair, and slapped his/her face. When staff attempted to redirect, he/she struck the staff. Again, he/she was transferred back to the emergency department and he/she struck staff. On admission that time, lab-work was again unremarkable, with exception of a urinalysis. He/she was readmitted to behavioral health, treated with an antibiotic for a urinary tract infection. His/her medication regimen was changed to Seroquel (antipsychotic medication) 25 mg three times a day, Depakote 500 mg every 12 hours, Remeron 15 mg at bedtime, and trazodone at bedtime as needed, as well as Haldol injection as needed. He/she was noted at this time to have aggressive behaviors, hitting and punching on the behavior health unit, and was noted to worsen with poor sleep, was confused and wandered, was noted to be very intrusive. He/she required a 1-on-1 caregiver/sitter. He/she gradually seemed to improve, and did transfer back to Memory Care on 3/7/19, on a regimen of Seroquel 100 mg three times daily, Depakote 500 mg every 12 hours, Remeron 30 mg at bedtime, and trazodone as needed. After readmission at this time to Memory Care, he/she was noted to have an unsteady gait and was wandering, bumping into things. The facility required the family to provide a 1-on-1 sitter due to the patient's unsteadiness, as well as difficult behaviors. The family became unhappy with that request and with the care, and transferred the patient to the current facility.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/18/19, showed the following:
-Short and long term memory problems;
-Moderately impaired cognitive skills for daily decision making:
-Trouble falling or staying asleep, or sleeping too much half or more days;
-Trouble concentrating half or more days;
-Short tempered, easily annoyed half or more days;
-Wandering behavior that significantly intruded on the privacy or activity of others occurred daily;
-Supervision required for walking in the room, corridors and unit;
-Diagnoses included Alzheimer's disease.
Review of the resident's care plan, dated 3/25/19, showed the following:
-Problem, physical behavioral symptoms directed at others;
-Goal, will not cause harm or injury to self or others over the next 90 days;
-Interventions, provide medication as ordered, monitor pattern of behavior, remind that behavior is not appropriate, remove from situation, and allow time to calm down. Known to exhibit outward physical behaviors by hitting, slapping, or pinching staff. If these behaviors are exhibited, staff will redirect, likes to play the piano.
Review of adverse event documentation, dated 4/10/19, showed the following:
-Resident #14: type of adverse event-physical aggression;
-Event description, while resident was ambulating in dining room he/she approached another resident and hit him/her on the right side of his/her face;
-The five why's - What happened? Aggressive behavior;
-Why? Resident was passing by another resident and the other resident's daughter was sitting with the resident that got hit. Action taken: removed resident from the area into the common area;
-Why? Resident became agitated. Action taken: attempted to redirect resident;
-Why? Resident will become restless and show aggression. Action taken: will attempt some approach to have resident involved with an activity;
-Why? Resident wanted other resident to go with him/her and he/she would not. Action taken: redirect to other areas and other activities.
-Final determination: resident is hard to redirect. Final action taken: keep resident occupied with other projects.
Review of the resident's progress notes, showed the following:
-On 4/10/19, resident was in the dining room when he/she passed another resident sitting by him/her and slapped him/her against the side of the right ear, family notified and physician, no new orders, just monitor resident;
-On 4/12/19 at 6:04 A.M., resident remains on incident follow up (IFU) for hitting another resident in the face, resident slept majority of the night and remains on 15 minute checks;
-On 4/12/19 at 9:30 P.M., resident remains on IFU related to hitting another resident in the face;
-On 4/13/19 at 6:41 A.M., resident remains on IFU for slapping another resident in the face. Resident displayed no behaviors this shift. Resident slept through the night. Resident continues on 15 min checks.
2. Review of Resident #62's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance required for most activities of daily living;
-Frequently incontinent of bowel and bladder;
-Wheelchair use;
-No behaviors;
-Diagnoses included high blood pressure and Alzheimer's disease.
Review of the resident's progress notes, showed the following:
-On 4/10/19 at 10:25 P.M., resident was sitting with family member in the dining room when another resident came over and slapped him/her, when he/she would not go with him/her. Resident's power of attorney (POA) was in dining room, physician and nursing supervisor made aware, no new orders;
-On 4/11/19 at 6:04 A.M., resident remains on IFU due to being hit in the face by another resident, resident shows no signs or symptoms of distress or discomfort;
-On 4/12/19 at 6:00 A.M., resident continues on IFU due to being hit in the face by another resident, resident shows no signs or symptoms of distress or discomfort;
-On 4/12/19 at 9:26 A.M., resident continues on IFU due to being slapped in the face by another resident, no signs or symptoms of distress or discomfort;
-On 4/13/19 at 6:30 A.M., resident continues on IFU due to being slapped in the face by another resident. Resident had no complaint of pain or discomfort this shift. Resident slept throughout the night. Will continue to monitor;
-On 4/13/19 at 11:05 P.M., Resident continues on IFU due to being slapped in the face by another resident. Resident had no complaint or discomfort this shift. Will continue to monitor.
3. During an interview on 6/11/19 at 8:11 A.M., Licensed Practical Nurse (LPN) I said he/she sometimes worked on the secured unit and did make the note about the incident on 4/10/19. He/she did not witness it but the family member of the resident who got slapped, did. Resident #62 lived on another floor now. He/she let the nurse manager know about the incident. Resident #14 was put on 15 minute checks and behavior monitoring.
4. During an interview on 6/11/19 at 9:57 A.M., Assistant Director of Nursing (ADON) N said he/she did an in-service on abuse, including requirements for reporting, about three weeks ago. The nurse manager in the secured unit was responsible for in-services done there.
5. During an interview on 6/11/19 at approximately 11:00 A.M., the administrator and Nurse Manager O said Resident #14's actions were behaviors related to dementia, not willful abuse and was not reported to the state agency. Nurse Manager O provided an in-service on abuse and neglect prevention, dated 1/31/19, with training objective of understanding the regulation that guides practices regarding freedom from abuse, neglect and exploitation.
6. During an interview on 6/11/19 at 11:33 A.M., Resident #62's POA said he/she was sitting at the table, with Resident #62, who sat in a wheelchair, when Resident #14 tried to move the resident's wheelchair, but the chair would not move. He/she told Resident #14 'no', and Resident #14 struck Resident #62 on the side of his/her head with an open hand. There was no injury but it startled the resident.
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 ensure services provided met professional standards of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by failing to provide weight parameters for daily ordered weights, notify the physician when a weight increase occurred and provide appropriate diagnoses with the use of antibiotic administration. This affected two of 28 sampled residents (Residents #142 and #344). The census was 205 with 140 residents in certified beds.
1. Review of Resident #142's medical record, showed:
-admitted to the facility on [DATE];
-Diagnoses of heart failure, vascular disease and kidney disease;
-Extensive assistance required for transfers and personal hygiene.
Review of the resident's admission electronic physician order sheet (ePOS), showed an order dated 5/21/19, for daily weights in the early morning. The order did not include weight parameters for when to contact the physician.
Review of the resident's care plan, in use at the time of the survey and reviewed on 6/6/19, showed the care plan did not address goals or interventions for daily weights.
Review of the resident's clinical notes, showed on 5/26/19 at 2:25 P.M., a new order received from the resident's physician to administer Lasix (diuretic) injection 20 milligrams (mg) one time due to weight increase of three pounds. Injection administered in the resident's left leg.
Review of the resident's June 2019, treatment administration record (TAR), showed the following weights:
-On 6/1/19: 195.00;
-On 6/2/19: 198.40.
Further review of the resident's clinical notes, showed staff did not notify the resident's physician or provide documentation regarding the weight gain of 3 pounds from 6/1/19 through 6/2/19.
Further review of the resident's June 2019 TAR, showed the following daily weights documented:
-On 6/3/19: 199.00;
-On 6/4/19: 198.30;
-On 6/5/19: no weight obtained, no documentation regarding the ordered daily weight;
-On 6/6/19: 198.00;
-On 6/7/19: 199.60.
Further review of the resident's clinical notes, showed no further documentation or physician notification of weight changes.
Further review of the resident's care plan, updated 6/7/19, showed:
-Problem: The resident is at risk for excess fluid related to edema (excessive fluid and swelling) and history of chronic heart failure;
-Goal: Fluid balance will be maintained;
-Interventions: Staff to monitor weights and signs and symptoms of chronic heart failure such as edema, shortness of breath, swollen neck veins and tiredness. Report changes to the physician.
2. Review of Resident #344's medical record, showed:
-admitted to the facility on [DATE]:
-Moderate cognitive impairment;
-Diagnoses of diabetes, surgical wound and kidney failure;
-Reinsertion of gastronomy tube (G-tube, hollow tube into the stomach used for nutrition needs);
-Received oral antibiotic for two days.
Review of the resident's medical record, showed the resident readmitted back to the facility 5/30/19, following G-tube dislodgement and replacement in the hospital emergency room and discharged with an order for an antibiotic for 2 days.
Review of the resident's ePOS, showed:
-An order dated 5/30/19 for Augmentin (antibiotic) 250 mg - 62.5 mg (combination medication) per (/) 5 milliliters (ml). Administer 15 ml every 12 hours for two days;
-The order did not provide a diagnoses for the antibiotic use.
Review of the resident's electronic medication administration record (eMAR), showed:
-An order dated 5/30/19 for Augmentin 250 mg - 62.5 mg/5 ml. Administer 15 ml every 12 hours for two days;
-Noted as completed on 5/30/19 and 6/1/19;
-The MAR did not provide a diagnoses for the antibiotic use.
Review of the admission baseline care plan, showed no antibiotic use and no replacement of the G-tube identified with goals and interventions.
3. During an interview on 6/10/19 at 10:59 A.M., the Director of Nursing said the resident had been admitted with heart failure and had an order for daily weights. It is important to monitor daily weights for residents with heart failure because the resident can quickly develop excessive fluid and worsen the heart failure. The order for daily weights should have been clarified upon admission and weight parameters included in the order. It is common to have a three pound weight gain as the parameter and staff should notify the physician immediately of weight gain. Staff should provide documentation and notes following an irregular weight finding. All antibiotics should have a matching diagnosis on the ePOS and the eMAR. Staff should complete baseline care plans upon readmission to include antibiotics and any procedures received outside of the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers (injury to the s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers (injury to the skin and/or underlying tissue as a result of pressure or friction) or are at risk for the development of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for two of two sampled residents with specialty mattresses on their beds (Residents #3 and #2). The census was 205 with 140 residents in certified beds.
1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/19, showed:
-Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD, lung disease), osteoarthritis and a history of a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) on the left buttock;
-Severe cognitive impairment with short and long term memory problems;
-No behaviors;
-At risk for pressure ulcer development;
-No pressure ulcers;
-63 inches tall and 98 pounds;
-Required total assistance from the staff for transfers, dressing, eating, hygiene and bathing.
Review of the resident's monthly weights, showed:
-January, 2019 - 107.10 pounds;
-February, 2019 - 108.9 pounds;
-March, 2019 - 106.10 pounds;
-April, 2019 - 103.70 pounds;
-May, 2019 - 101.10 pounds;
-June, 2019 - 101.60 pounds.
Review of the resident's Braden scale assessment (assessment for pressure ulcer risk), dated 6/3/19, showed a score of 8 (0 to 9 indicates a very high risk for development of pressure ulcers).
Observation on 6/5/19 at 10:11 A.M., showed the resident out of the room. The low air loss mattresses (LAL, a mattress designed to prevent and treat pressure wounds) on the bed had been set at 250 pounds.
Observations on 6/6/19 at 11:16 A.M., showed the resident out of the room and the LAL mattress remained set at 250 pounds. At 2:25 P.M., the resident lay in bed asleep with the LAL mattress set at 250 pounds.
Observations on 6/7/19 at 7:20 A.M., showed the resident lay in bed asleep. The LAL mattress remained set at 250 pounds. At 8:00 A.M., staff provided the resident with care and transferred him/her into his/her recliner. Staff did not adjust the setting on the LAL mattress and the setting remained at 250 pounds.
Observation on 6/10/19 at 9:05 A.M., showed the resident out of the room. The low air loss mattress on the bed had been set at 150 pounds.
During an interview on 6/10/19 at 10:21 A.M., the Director of Nurses (DON) verified the residents LAL mattress had been set to 150 pounds.
2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:
-Short and long term memory problems;
-Moderately impaired cognitive skills for daily decision making;
-Extensive assistance of staff for bed mobility;
-Upper and lower extremity impairment on both sides;
-Incontinent of bowel and bladder;
-Weighed 91 pounds;
-At risk for pressure ulcers;
-Diagnoses included Alzheimer's disease, contractures (loss of range of motion), depression and anxiety.
Review of the resident's care plan, effective 7/14/17 to present, showed the following:
-Problem, at risk for developing impaired skin integrity related to poor bed mobility and incontinence of bowel and bladder;
-Goal, will have no alteration in skin integrity through next review;
-Interventions, weekly skin assessment, complete Braden Scale quarterly and as needed, minimize pressure over boney prominences.
Observation of the resident, showed the following:
-On 6/7/19 at 6:51 A.M., the resident lay in a low bed with a LAL mattress set between 200 and 250 pounds;
-On 6/10/19 at 3:08 P.M., the resident lay in a low bed with the LAL mattress set between 200 and 250 pounds;
-On 6/11/19 at 7:05 A.M., the resident lay in a low bed with the LAL mattress set between 200 and 250 pounds.
3. During an interview on 6/10/19 at 10:21 A.M., the DON said the LAL mattress should be set according to the resident's weight, if set too high it puts pressure on the skin and can cause pressure ulcers due to mattress being too hard of a surface. The charge nurse is responsible for checking the LAL mattress daily to ensure they are set for the appropriate weight of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services for 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 ensure appropriate treatment and services for residents who used indwelling urinary catheters by failing to ensure residents had complete physician orders for the catheter use to include catheter size, balloon size and diagnoses. The facility also failed to ensure appropriate catheter drainage bag positioning and ensure the urinary drainage bag remained covered. This affected four of five facility identified residents that used indwelling urinary catheters (Residents #66, #138, #142 and #90). The census was 205 with 140 residents in certified beds.
Review of the facility's urinary catheter (a tube placed into the bladder to drain urine) care policy, revised on 11/19/18, showed:
-Purpose: To prevent catheter associated urinary tract infections (UTIs);
-Maintaining unobstructed urine flow: Check the resident frequently to make sure they are not lying on the tubing and to keep the catheter and tubing free of kinks. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the resident's bladder;
-Changing catheters: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction or when the closed system is compromised.
1. Review of Resident #66's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/20/19, showed the following:
-Cognitively intact;
-Two person staff assistance for bed mobility and transfers;
-One person staff assistance for dressing, eating, toilet use and personal hygiene;
-Upper extremity impairment on both sides;
-Lower extremity impairment on both sides;
-Diagnoses included obstructive uropathy (a condition in which the flow of urine is blocked) and diabetes.
Review of the resident's physician order sheet (POS), dated 6/1/19 through 6/30/19, showed an order, dated 3/26/19, to change suprapubic catheter (a urinary catheter surgically inserted through the abdominal wall, used to drain urine) monthly with 18 French (fr, size)/5 cubic centimeter (cc) balloon catheter via sterile technique.
Review of the resident's care plan, in use during the survey, showed:
-Problem: Suprapubic catheter due to obstructive and reflux uropathy (18 fr/5 cc balloon);
-Interventions: Will remain free of UTI during period of catherization;
-Goals: Keep tubing below level of bladder and free of kinks or twists. Cover indwelling urinary catheter drainage bag with a dignity bag.
Observations of the resident during the survey, showed:
-On 6/05/19 at 10:29 A.M., the resident lay in his/her bed, the catheter bag hung from the side of the bed, observable from the doorway with no dignity bag provided;
-On 6/07/19 at 8:15 A.M., the resident lay in his/her bed, the catheter bag hung from the side of the bed, observable from the doorway with no dignity bag provided;
-On 6/10/19 at 2:12 P.M., the resident sat in his/her electric wheelchair reclined with one foot propped on his/her bed. The catheter bag hung from the side of the wheelchair with no dignity bag provided. The catheter tubing looped above the arm rest of the resident's wheelchair, above the level of the resident's bladder.
Observation and interview on 6/10/19 at 2:50 P.M., showed the resident seated in his/her electric wheelchair, reclined with one foot propped on his/her bed. The catheter bag hung from the side of the wheelchair with no dignity bag provided. The catheter tubing looped above the arm rest of the resident's wheelchair. Nurse M said the catheter tubing was looped above the resident's bladder and staff should check on the resident periodically to ensure the catheter and tubing were positioned below the bladder.
2. Review of Resident #138's quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Two person staff assistance for bed mobility, toilet use and transfers;
-One person staff assistance for dressing, eating, and personal hygiene;
-Upper extremity impairment on both sides;
-Lower extremity impairment on both sides;
-Mobility, wheelchair;
-Diagnoses included multiple sclerosis (a neurological autoimmune disease) and anemia.
Review of the resident's POS, dated 6/1/19 through 6/10/19, showed an order, dated 3/26/19, to change the suprapubic catheter monthly with a 18 fr/5 cc balloon catheter.
Review of the June 2019 Treatment Administration Record (TAR), showed a treatment order to change suprapubic catheter once every month. Use 18 fr/5 cc balloon catheter.
Review of the resident's care plan, in use during the survey, showed:
-Problem: Suprapubic catheter related to his/her chronic wounds and history of UTI. (18 fr/10 cc balloon);
-Interventions: Will remain free of UTIs during period of catherization;
-Goals: Change catheter bag as ordered. Keep tubing below level of bladder and free of kinks or twists. Monitor for signs/symptoms of UTI;
-Further review of the care plan, showed the catheter balloon size did not match the physician's treatment ordered size of 18 fr/5 cc;
-Goals did not include the use of a privacy bag per the facility policy.
Observations of the resident during the survey, showed the following:
-On 6/5/19 at 12:38 P.M., the resident lay in his/her bed, the catheter bag hung from the side of the bed, observable from the doorway with no dignity bag provided;
-On 6/6/19 at 11:23 A.M., the resident lay in his/her bed, the catheter bag hung from the side of the bed, observable from the doorway with no dignity bag provided;
-On 6/7/19 at 8:10 A.M., the resident lay in his/her bed, the catheter bag hung from the side of the bed, observable from the doorway with no dignity bag provided;
-On 6/10/19 at 2:12 P.M., the resident lay in his/her bed, the catheter bag hung from the side of the bed, observable from the doorway with no dignity bag provided;
-On 6/11/19 at 7:16 A.M., the resident lay in his/her bed, the catheter bag hung from the side of the bed, observable from the doorway with no dignity bag provided.
3. Review of Resident #142's medical record, showed;
-admitted to facility on 5/24/19;
-Extensive staff assistance needed for positioning and hygiene;
-Used an indwelling urinary catheter;
-Diagnoses of vascular disease, kidney disease, and UTI.
Review of the resident's June 2019 POS, showed:
-An order dated 5/30/19 to change indwelling urinary catheter every 15 days;
-The order did not contain the diagnosis for catheter use, catheter size, catheter balloon size and recommended frequent catheter changes with no supporting documentation for the need for catheter changes more frequently than recommended.
Review of the resident's June 2019 TAR, showed an order dated 5/30/19, to change indwelling urinary catheter every 15 days and scheduled to be completed on 6/14/19. The order did not contain the diagnosis for catheter use, catheter size, catheter balloon size and recommended frequent catheter changes with no supporting documentation for the need for catheter changes more frequently than recommended.
During an interview on 6/05/19 at 10:02 A.M., the resident said he/she had been admitted to the facility with the catheter. The facility staff had not discussed with him/her the option to remove the catheter and he/she had been in the hospital as a result of a UTI. Observation at this time, showed the urinary drainage bag hung exposed and uncovered under the resident's wheelchair.
Review of the resident's care plan, dated 6/6/19, showed:
-Problem: The resident uses a Indwelling urinary catheter related to obstruction and retention;
-Goal: The catheter will function and drain;
-Interventions: The catheter will remain in place as ordered, keep catheter drainage bag covered with a dignity bag.
Observations during the survey, showed:
-On 6/6/19 at 10:04 A.M., the resident out in the unit lobby. His/her urinary catheter bag hung visible under the seat of the wheelchair. Approximately 200 cc of yellow urine noted in the drainage bag;
-At 12:45 P.M., the resident watched TV in his/her room, with the door opened to the hallway and the drainage bag visible from the hallway under his/her wheelchair;
-On 6/07/19 at 8:02 A.M., the resident sat in the main dining room at the breakfast table. The indwelling urinary catheter drainage bag attached to the wheelchair leg rest bar with the drainage bag approximately 1/4 full of yellow urine;
-At 9:15 A.M., the resident propelled him/herself out of the dining room down the hallway toward his/her room. He/she passed by six staff members with the catheter drainage bag visible under the seat of the wheelchair;
-At 12:32 P.M., the resident sat in the main dining room, the urinary drainage bag visible under the wheelchair, approximately 200 cc of yellow urine visible;
-On 6/10/19 at 11:08 A.M., the resident sat in his/her wheelchair in his/her room, the door open to the hallway. The indwelling urinary catheter drainage bag attached to the wheelchair leg rest bar and visible from the hallway.
4. Review of Resident #90's medical record, showed the following:
-Cognitively intact;
-Two person staff assistance for bed mobility and transfers;
-One person staff assistance for dressing, toilet use and personal hygiene;
-Mobility, wheelchair;
-Diagnoses included cirrhosis (chronic liver damage from a variety of causes, leading to scarring and liver failure), kidney failure, septicemia (a life-threatening complication of an infection) and cerebral palsy (congenital disorder of movement, muscle tone, or posture).
Review of the resident's POS, dated 6/1/19 through 6/10/19, showed an order, dated 3/26/19, to change the suprapubic catheter monthly with 18 fr/10 cc balloon catheter.
Review of the resident's care plan, in use during the survey, showed:
-Problem: Suprapubic catheter due to urinary retention, (18 fr/10 cc balloon);
-Interventions: Will remain free UTI during period of catherization;
-Goals: Change catheter bag as ordered. Keep tubing below level of bladder and free of kinks or twists. Monitor for signs/symptoms of UTI. Cover indwelling urinary catheter drainage bag with dignity bag.
Observation on 6/11/19 at 7:32 A.M., of the resident during a Hoyer (mechanical lift) transfer, showed the resident lay flat on his/her bed on top of the Hoyer pad with his/her Hoyer pad connected to the Hoyer lift. While he/she lay on his/her back, the indwelling urinary catheter lay on top of his/her abdomen, above the level of the bladder. CNA L took hold of the resident's hand and placed the resident's hand on his/her indwelling urinary catheter bag and instructed the resident to hold on to his/her indwelling urinary catheter bag during the transfer. Cloudy yellow urine was visible in the Indwelling urinary catheter tubing.
5. During an interview on 6/10/19 at 11:08 A.M., the Director of Nursing said if the resident had a catheter, the resident's physician order sheet should have the catheter size and catheter balloon size. Catheters should not be changed routinely and the nurse should clarify catheter change orders. Frequent changes could promote infection risk. Drainage bags should always be placed and secured below the level of the bladder to prevent the risk of urine flowing back into the bladder and causing an infection. Drainage bags should be covered with dignity bags and not exposed. The drainage bag should always be covered and not visible to other residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide oxygen therapy consistent with professional st...
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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 oxygen therapy consistent with professional standards of practice for three of four residents investigated for respiratory care, who received oxygen therapy (Residents #3, #65 and #23). The sample was 28. The census was 205 with 140 residents in certified beds.
Review of the facility's policy for Oxygen Administration, dated 12/10/17 and revised on 7/23/18, showed:
-Oxygen humidifier bottle and tubing should be changed monthly;
-Oxygen tubing should be stored in a plastic bag when not in use.
1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/19, showed:
-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease);
-Received oxygen therapy.
Review of the resident's electronic physician order sheet (ePOS), showed an order dated 1/15/18, to administer oxygen at 2 liters (L) per minute by nasal cannula (NC) for oxygen saturation (amount of oxygen in the blood) levels of less than 93%.
Review of the resident's care plan, dated 6/7/17, and in use during the survey, showed staff had not care planned the resident for the use of the oxygen.
Observation on 6/5/19 at 10:11 A.M., showed the resident out of the room. An oxygen concentrator sat in the room next to the bed. The oxygen tubing draped over the top of the concentrator, without any type of protective bag or barrier and the nasal prongs directly touched the top of the concentrator.
Observations on 6/6/19 at 11:16 A.M., showed the resident out of the room and the oxygen concentrator turned off. The oxygen tubing draped over the top of the concentrator, without any type of protective bag or barrier and the nasal prongs directly touched the top of the concentrator. At 2:25 P.M., the resident lay in bed sleeping without any oxygen in place. The oxygen tubing remained draped over the top of the concentrator with the nasal prongs directly touching the top of the concentrator.
Observations on 6/7/19 at 7:20 A.M., showed the resident lay in bed asleep, with the same oxygen tubing in his/her nose and the oxygen concentrator set at 2 liters per minute per NC. At 8:00 A.M., staff provided the resident with care. Certified Nurse Assistant (CNA) C removed the oxygen from the resident, coiled the oxygen tubing and placed it on top of the concentrator and the nasal prongs lay directly on and touched the side of the concentrator. CNA C did not place the oxygen tubing in any type of bag or protective covering. CNA C said the resident only used the oxygen at night.
Observation on 6/10/19 at 9:05 A.M., showed the resident out of the room. The uncovered oxygen tubing lay coiled on top of the concentrator.
During an interview on 6/11/19 at 10:02 A.M., the Assistant Director of Nurses (ADON) said she would have expected staff to change the oxygen tubing as well as place it in the plastic bag due to infection control issues.
2. Review of Resident #65's quarterly MDS, dated [DATE], showed:
-Diagnoses included pleural effusion (an abnormal accumulation of fluid in the space between the lungs and the chest wall) and COPD;
-Oxygen therapy not marked.
Review of the resident's ePOS, showed an order dated 5/1/17, to administer oxygen at 2 to 4 L a minute by NC as needed.
Review of the resident's care plan, dated 7/13/17 and in use during the survey, showed:
-Problem: Resident has alteration in respiratory status due to COPD;
-Goal: Resident will demonstrate improved breathing, less exertion and increased activity tolerance;
-Interventions included: Evaluate shortness of breath for pain/discomfort with breathing. Provide oxygen as ordered.
Observation on 6/5/19 at 10:09 A.M., on 6/6/19 at 11:12 A.M. and 2:25 P.M., on 6/7/19 at 7:22 A.M. and on 6/10/19 at 9:05 A.M., showed an oxygen concentrator located beside the resident's bed and turned off. The uncovered oxygen tubing draped over the top of the concentrator and the nasal prongs directly touched the floor.
During an interview on 6/10/19 at 10:21 A.M., the Director of Nurses (DON) verified the resident's uncovered oxygen tubing with the nasal prongs directly on the floor, said the facility policy is to place the oxygen tubing in a plastic bag when not in use and it would never be appropriate for tubing to be on the floor due to infection control issues.
During an interview on 6/11/19 at 10:02 A.M., the ADON said she would have expected staff to change the oxygen tubing as well as place it in the plastic bag due to infection control issues.
3. Review of Resident #23's admission MDS, dated [DATE], showed:
-Diagnoses included COPD, shortness of breath and dependence on supplemental oxygen;
-Oxygen therapy marked.
Review of the resident's ePOS, showed an order dated 12/10/18, to administer oxygen at 2 to 5 L by NC as needed to keep oxygen saturation level greater than 90%.
Review of the resident's care plan, dated 12/16/18, and in use during the survey, showed:
-Problem: Resident is unable to maintain oxygen saturation. Receives oxygen at 2 to 4 L a minute;
-Goal: Resident will maintain an adequate oxygen saturation greater than 92%;
-Interventions: Change tubing and humidifier bottle monthly and as needed.
Observation on 6/5/19 at 10:41 A.M., showed the resident out of his/her room and an oxygen concentrator located in the room. The uncovered oxygen tubing coiled and placed on top of the concentrator.
Observation on 6/6/19 at 9:10 A.M. and at 2:30 P.M., showed the resident out of his/her room. The uncovered oxygen tubing lay in the seat of his/her cloth recliner and the nasal prongs directly touched the seat of the recliner.
Observation on 6/10/19 at 9:10 A.M., and at 4:16 P.M., showed the resident out of his/her room. The uncovered oxygen tubing lay coiled on top of the concentrator the nasal prongs directly touched the concentrator.
During an interview on 6/10/19 at 10:21 A.M., the DON verified the resident's uncovered oxygen tubing, said the facility policy is to place the oxygen tubing in a plastic bag when not in use and it would never be appropriate for tubing to be on the floor, seat of a chair or touching the sides of the concentrator due to infection control issues. The charge nurse is responsible for checking the oxygen daily to ensure the tubing is in a protective bag when not in use and set the oxygen at the appropriate rate when in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure the facility provided services in sufficient nu...
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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 assure the facility provided services in sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Licensed nurses and other nursing personnel, including but not limited to nurse aides, by failing to assure facility staff were assigned to and provided care for three of three spine or orthopedic surgery center residents followed by a contracted spine and orthopedic surgery center for post-surgical care (Residents #244, #245 and #246). The contract between the surgical center and facility specified that the clinic staff would provide services related to intravenous medication administrations. The agreement did not specify that any other direct resident care or services were to be provided to the resident by the surgical center. The sample was 28. The census was 205 with 140 residents in certified beds.
Review of the facility's Clinical Support Services Agreement, dated 3/1/11, between the facility and a spine and orthopedic surgery center, showed the facility agreed:
-That the center would provide clinical support services related to intravenous (IV) medication administration to patients transferred from the center to the facility on the rehab wing only when a center registered nurse is on duty at the facility and a facility registered nurse is not available;
-The center would provide services in a manner consistent with all professional practices and standards and that all staff shall maintain in good standing all licenses, certifications, and other authorizations required to provide professional services at the facility;
-The service agreement did not identify the responsibility to assess the residents, monitor the resident's neurological status, monitor vital signs, answer the call lights and assist the residents as they require.
1. During the entrance interview on 6/5/19, the Director of Nurses (DON) said the facility currently had two residents from the Spine and Orthopedic Surgery Center, who were admitted on [DATE], and would be discharged that morning after they completed their IV antibiotic medication. The residents were in the facility for IV fluids, IV medications and observation after they had surgery.
2. Observation and interview on 6/6/19 at 6:40 A.M., showed three residents resided on the Arborview 2 hallway. The surgical center nurse, Nurse G, said he/she is not an employee of the facility, but is an employee of the Surgery Center. He/she had been working 2 to 4 nights a week at the facility from 6:00 P.M. until 6:00 A.M., taking care of the Surgery Center patients, which is an outpatient surgery center. He/she assessed the residents, monitored their neurological status, monitored vital signs and IV access sites, answered the call lights and assisted the residents as they required. He/she does not have access to the facility computer system, so all of his/her documentation is hand written on paper, which is left for the facility. He/she started working at the facility in this capacity in March, 2019. If there was an emergency, he/she would dial and page overhead for the facility staff.
3. Review of Resident #244's medical record, showed the resident followed by a contracted spine and orthopedic surgery center for post-surgical care:
-admitted [DATE] at 9:12 P.M.;
-No admitting diagnosis specified;
-discharged [DATE] at 11:19 A.M.
4. Review of Resident #245's medical record, showed the resident followed by a contracted spine and orthopedic surgery center for post-surgical care:
-admitted [DATE] at 6:20 P.M.;
-No admitting diagnosis specified;
-discharged [DATE] at 11:25 A.M.
5. Review of Resident #246's medical record, showed the resident followed by a contracted spine and orthopedic surgery center for post-surgical care:
-admitted [DATE] (no time specified);
-No admitting diagnosis specified;
-discharged [DATE] at 11:16 A.M.
6. During an interview on 6/6/19 at 8:20 A.M., a facility nurse, Nurse H, verified there were 3 residents on Arborview 2 and said he/she is the only facility staff person who worked that hall. The surgical center nurse is on the hall to take care of the resident's. The resident's are all alert and oriented to person, place and time and if they need something they will put on the call light or can use their own phone to call for assistance. He/she verified the surgical center nurse, Nurse G, assesses the residents, monitors their neurological status, IV fluids and vital signs, answers their call lights and assists the residents as needed. Nurse H works from 11:00 P.M. until 7:00 A.M. on Meadowview 2 Hall, gets report from the surgical center nurse, Nurse G, and will assist Nurse G if he/she needs assistance. All 3 residents are from the surgery center and therefore, he/she believed, they do not fall under any federal or state regulations. Nurse H stays over on the day shift to care for the surgery center residents until they are discharged home. If he/she cannot stay, then either the DON or another Licensed Nurse will assume the resident's care until discharge.
7. During an interview on 6/7/19 at 11:00 A.M., the DON said the facility had been admitting residents from spinal surgical center for over one year.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 29 opportunities observed, two errors occurred, resulting in a 6.89% me...
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Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 29 opportunities observed, two errors occurred, resulting in a 6.89% medication error rate (Resident #344). The census was 205 with 140 residents in certified beds.
Review of the facility Policy and Procedure for Administering Medication, dated 1/25/17 and reviewed on 9/25/18, showed:
-Policy Statement: Medication shall be administered in a safe and timely manner and as prescribed. The community shall provide residents with necessary medication(s) when they leave the community temporarily;
-Policy Interpretation and Implementation:
-Medications must be administered in accordance with the orders, including the required time frame;
-If the dosage is believed to be inappropriate or excessive for the resident, or a medication has been identified as having potential adverse consequence for the resident or is suspected of being associated with adverse consequences, the person preparing or administrating the medication shall contact the resident's physician or the community Medical Director to discuss the concerns;
-The individual administering the medication must check the label three times to verify the right medication, right dose and right time before giving the medication.
Review of Resident #344's medical record, showed:
-Gastronomy tube (G-tube, a hollow tube placed through the abdominal wall into the stomach used to provide nutrition and medications) in place;
-Diagnoses of Gastro-esophageal reflux disease (GERD, heart burn), irregular heartbeat, stroke and kidney disease related to high blood pressure.
Review of the June 2019 electronic physician order sheet (ePOS), showed:
-An order dated 5/30/19, for losartan (used to treat high blood pressure) 100 milligram (mg). Administer one tablet by G-tube once daily for 12 months. The order did not include blood pressure parameters or instructions to hold the medication if blood pressure is out of range;
-An order dated 5/30/19, for esomeprazole magnesium (used to treat GERD) 20 mg. Administer one tablet by G-tube once daily.
During an observation and interview on 6/7/19 at 8:47 A.M., Licensed Practical Nurse (LPN) I prepared to administer the resident's morning medication by G-tube. LPN I obtained the resident's blood pressure (normal less than 120/80) and showed the surveyor the result of 107/56. He/she placed two 20 mg tablets of esomeprazole magnesium into a plastic sleeve and crushed the medication and dispensed the medication into a plastic medication cup, not the 20 mg one tablet as ordered. He/she poured 10 cubic centimeters (cc) of water into the medicine cup and administered the medication to the resident. He/she did not administer the ordered losartan 100 mg and said he/she will not administer the medication related to the resident's blood pressure results. He/she verified the POS did not include blood pressure parameters to hold the medication and he/she would notify the resident's physician to hold the medication.
Review of the resident's clinical notes on 6/7/19 at 12:53 P.M., showed no documentation regarding the held losartan 100 mg dose.
During an interview on 6/7/19 at 2:12 P.M., the Director of Nursing (DON) said medications should be administered as ordered. Staff should clarify and verify orders before administering medications. If staff question a blood pressure result, they should contact the physician right away to clarify the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable by failing to properly date and label insulin flexpens (prefilled injectable insulin) and insulin vials for six of 15 insulin pen or vial observations. The census was 205 with 140 residents in certified beds.
1. Review of the facility's storage of medication policy, dated [DATE], showed:
-Policy statement: The community shall store all drugs and biologicals in a safe, secure and orderly manner;
-Policy interpretation and implementation: Drug containers that have missing, incomplete, improper or incorrect labels should be returned to the pharmacy or destroyed.
2. Review of the facility Policy and Procedure for Administering Medication, dated [DATE], and reviewed on [DATE], showed:
-Policy Interpretation and Implementation:
-Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an Insulin pen, the individual administering the medication will verify that the correct pen is used for that resident.
3. Observation on [DATE] at 1:50 P.M., of the [NAME] medication cart, showed one Novolog (short acting insulin) flex pen undated, opened and in use.
4. Observation on [DATE] at 1:59 P.M., of the [NAME] medication cart, showed:
-One Levimer (long acting insulin) Flexpen undated, opened and in use;
-One Humalog (short acting insulin) vial undated, opened and in use.
5. Observation on [DATE] at 2:10 P.M., of the Honeysuckle medication cart, showed:
-One Novolog flexpen in use, not labeled with a resident name and undated;
-One Levimer flexpen, dated 5/30 and not labeled with a resident name;
-One Humalog vial in use and undated.
6. During an interview on [DATE] at 2:33 P.M., the Director of Nursing said that every insulin vial or pen needed to have the resident's name and the date the pen or vial was removed from the refrigerator and opened. The nurse or certified medication technician needs to check the vial or pen before administration of the insulin. The insulin should not be administered if the pen or vial is not labeled correctly. The staff should dispose of incorrect pens or vials and obtain a new vial or pen from the stock insulin supply. The staff should then label that vial or pen with the resident's information and the date it was opened. The use of undated insulin may not be as effective since the insulin could be expired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
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 conduct and document a complete facility-wide assessme...
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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 conduct and document a complete facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies by not identifying a resource of agency staff used to fulfill staffing needs, address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement and volunteers, consistent with their expected roles, and include an evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies. The census was 205 with 140 residents in certified beds.
Review of the facility's Clinical Support Services Agreement, dated 3/1/11, between the facility and a spine and orthopedic surgery center, showed the facility agreed:
-That the center would provide clinical support services related to intravenous (IV) medication administration to patients transferred from the center to the facility on the rehab wing only when a center registered nurse is on duty at the facility and a facility registered nurse is not available;
-The center would provide services in a manner consistent with all professional practices and standards and that all staff shall maintain in good standing all licenses, certifications, and other authorizations required to provide professional services at the facility.
Review of the facility's undated Facility-Wide Assessment, showed:
-The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in the facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being;
-The Facility-Wide Assessment failed to address care provided by facility staff or contracted staff, for the spine and orthopedic surgery center patients;
-The Facility-Wide Assessment failed to address staffing, facility staff or contracted staff, required for the spine and orthopedic surgery center patients;
-The Facility-Wide Assessment failed to address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement consistent with their expected roles;
-The Facility-Wide Assessment failed to include an evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies.
During the entrance interview on 6/5/19, the Director of Nurses (DON) said the facility had two patients from the Spine and Orthopedic Surgery Center, who were admitted on [DATE], and would be discharged that morning after they completed their IV antibiotic medication. They were in the facility for IV fluids, IV medications and observation after they had surgery.
Observation and interview on 6/6/19 at 6:40 A.M., showed three residents resided on the Arborview 2 hallway. Nurse G said he/she is not an employee of the facility, but is an employee of the Surgery Center. He/she had been working 2 to 4 nights a week at the facility from 6:00 P.M. until 6:00 A.M. taking care of the Surgery Center patients, which is an outpatient surgery center. He/she assess the patients, monitors neurological status, monitors vital signs and IV access, answers their call lights and assists the residents as they require. He/she does not have access to the facility computer system, so all of his/her documentation is hand written on paper, which is left for the facility. He/she started working at the facility in this capacity in March, 2019. If there was an emergency, he/she would page overhead for the facility staff.
During an interview on 6/6/19 at 8:20 A.M., Nurse H verified there were three patients on Arborview 2 and said he/she is the only staff person working that hall. All three patients are from the surgery center and therefore do not fall under any federal or state regulations. They are all alert and oriented to person, place and time and if they need something, they will put on call light or can use their own phone to call for assistance. He/she verified Nurse G assesses the patients, monitors neurological status, IV fluids and vital signs, answers their call lights and assists the residents as needed. Nurse H works from 11:00 P.M. until 7:00 A.M. on Meadowview 2 Hall, gets report from Nurse G and will assist Nurse G if he/she needs assistance. Nurse H stays over on the day shift to care for the surgery center patients until they are discharged home. If he/she cannot stay, then either the DON or another Licensed Nurse will assume the resident's care until discharge.
During an interview on 6/7/19 at 11:00 A.M., the Director of Nursing (DON) said the facility assessment is updated annually. She confirmed that the contract was signed on 3/1/18. The facility had been admitting residents from spinal surgical center for over one year. She would expect the facility assessment to include third party contracts. The spinal surgical center was not documented in the facility assessment. She would expect the assessment to include the level of care and services that are provided to post-surgical spinal patients. It should include all the needs and services and who will provide the care. The surgeon's nurse and facility staff are expected to be included in the facility assessment with detail of who would be responsible for the type of care or service. The DON would expect the assessment to include expectations in case of emergency, who would be responsible for providing care and training that is needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 maintain medical records on each resident that are complete, accura...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible, in accordance with accepted professional standards and practices, for three of three spine or orthopedic surgery center residents followed by a contracted spine and orthopedic surgery center for post-surgical care (Residents #244, #245 and #246). The sample was 28. The census was 205 with 140 residents in certified beds.
1. Review of Resident #244's medical record, showed the resident followed by a contracted spine and orthopedic surgery center for post-surgical care:
-admitted [DATE] at 9:12 P.M.;
-An order dated 6/5/19, for neurological checks per shift;
-An order dated 6/5/19, for vital signs per shift;
-Vital signs (blood pressure, pulse, temperature, respirations, oxygen saturation and pain) documented on 6/5/19 at 9:49 P.M.;
-No further vital signs documented;
-No documentation of neurological checks completed;
-No admitting diagnosis specified;
-No advanced directives specified;
-No facility admission form;
-No documentation of assessments completed;
-discharged [DATE] at 11:19 A.M.
2. Review of Resident #245's medical record, showed the resident followed by a contracted spine and orthopedic surgery center for post-surgical care:
-admitted [DATE] at 6:20 P.M.;
-An order dated 6/5/19, for neurological checks per shift;
-An order dated 6/5/19, for vital signs per shift;
-Vital signs (blood pressure, pulse, temperature, respirations, and oxygen saturation) documented on 6/5/19 at 6:25 P.M. and 9:51 P.M.;
-No further vital signs documented;
-No documentation of neurological checks completed;
-No admitting diagnosis specified;
-No advanced directives specified;
-No facility admission form;
-No documentation of assessments completed;
-discharged [DATE] at 11:25 A.M.
3. Review of Resident #246's medical record, showed the resident followed by a contracted spine and orthopedic surgery center for post-surgical care:
-admitted [DATE] (no time specified);
-An order dated 6/5/19, for neurological checks per shift;
-An order dated 6/5/19, for vital signs per shift;
-Vital signs (blood pressure, pulse, temperature, respirations, and oxygen saturation) documented on 6/5/19 at 10:51 P.M.;
-No further vital signs documented;
-No documentation of neurological checks completed;
-No admitting diagnosis specified;
-No advanced directives specified;
-No facility admission form;
-No documentation of assessments completed;
-discharged [DATE] at 11:16 A.M.
4. During an interview on 6/7/19 at 11:00 A.M., the Director of Nursing (DON) said the post-surgical residents' medical record documentation is located in the electronic medical record or the paper flow sheet. Both the surgeon's nurse and the facility nursing staff are responsible for obtaining the resident's neurological checks and vital signs, as well as other assessments; however, the facility staff does more of the medical management. Prior to the resident's discharge from the hospital, the DON receives report from the surgical center. The facility picks up the resident and transports them to the facility. The facility will check the resident's pain level and physician orders. The physician orders are signed and handwritten from the doctor. The facility staff monitors the resident and provides care until 6:00 P.M., when the surgeon's nurse arrives. The DON provides information such as concerns, assessments, and what medications were administered to the surgeon's nurse. The surgeon's nurse takes over from 6:00 P.M. to 6:00 A.M. The surgeon's nurse does not document anything on the facility's electronic medical record, only on paper form. At 6:00 A.M., the surgeon's nurse gives report to the facility nurse supervisor. The information that was documented from the surgeon's nurse is left with the facility. Once the facility staff takes over, they are expected to obtain neurological checks and vital signs as ordered. They are either handwritten on the same flow sheet or in the electronic medical record. The signed code status and advanced directives for the surgical clinic residents is in the paperwork from the surgical center. The facility does not obtain a signed code status sheet for the facility and they would follow the orders from the surgical center. If a resident does not have a code status specified, the facility would automatically assume they were a full code. Physician orders should be documented as completed in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedures for a resident on isolation precautions for one sampled resident who was on isolation precautions for an infectious disease (Resident #111). In addition, the facility failed to maintain appropriate infection control by failing to ensure staff handled medications properly to prevent the potential spread of infection during medication administration when staff used bare hands to administer medications to one resident (Resident #124). The sample was 28. The census was 205 with 140 residents in certified beds.
1. Review of the facility's care of the resident with Clostridium Difficile infection (C-diff, a bacterial infection that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon), revised 1/29/18, showed:
-Statement: Appropriate measures will be utilized to prevent and control C-diff infections. Transmission based precautions will be determined based on the guidelines and on individual basis;
-Case definition: The presence of diarrhea of three or more unformed stools in a 24 hour time period and a positive stool test result for the presence of toxigenic C. difficile spores and toxins;
-A history of treatment with antibiotic agents within the previous eight weeks is present in a majority of patients, fever, abdominal pain or tenderness, loss of appetite and nausea may be present;
-C. diff spores are shed in the feces. Any surface, device or material that becomes contaminated with feces may serve as a reservoir for the spores for up to six months. C-diff spores are transferred mainly via hands of the healthcare provider who had touched contaminated surfaces or items;
-Interpretation and implementation:
-If the resident meets the above criteria, the physician should be notified for orders and appropriate testing;
-Residents with diarrhea associated with C. diff will be placed on contact precautions:
-The staff will wear gloves and gown upon entering the room of the resident with C. diff infection and will remove the gowns and gloves before exiting the resident's room and perform proper hand hygiene;
-Visitors will be encouraged to wear gowns and gloves, and instructed on proper hand hygiene and C. diff infections;
-Residents with diarrhea and suspected C. diff infection will be placed on contact precautions while awaiting laboratory results;
-When caring for resident's with diarrhea caused by C. diff, staff will maintain vigilant hand hygiene. Hand washing with soap and water is superior to alcohol based hand rub for the removal of the C. diff spores from the hands;
-C. diff infection tracking is part of routine surveillance and should be tracked via the quality risk management tool and reported to the QAPI committee.
Review of Resident #111's medical record, showed:
-A hospital discharge summary note, dated 5/8/18, showed a discharge diagnosis of C-diff. The last dose of oral antibiotics on 5/3/19 and no further diarrhea noted;
-Treated in the hospital for C. diff infection and discharged to the facility on 5/9/19;
-Cognitively intact;
-Extensive staff assistance needed for toileting, hygiene and transfers;
-Frequently incontinent of bowel and bladder;
-Diagnoses of C-diff infection, gastrointestinal hemorrhage (bleed), sepsis (blood infection) and urinary tract infection (UTI).
Review of the resident's clinical notes, showed:
-On 5/13/19 at 5:05 A.M., the aide reported the resident experienced loose stools. The oncoming day shift nurse is aware and will monitor;
-On 5/26/19 at 10:38 P.M., the resident incontinent of stool. The stool noted foul smelling with mucous mixed within. The physician notified and new orders to obtain a stool sample for C-diff testing;
-On 5/27/19 at 5:57 A.M., the resident had several episodes of foul smelling liquid stools. Ordered stool sample obtained.
Further review of the medical record, showed a stool culture result, dated 5/27/19, showed positive for C. diff toxigenic spores.
Further review of the resident's clinical notes, showed:
-On 5/27/19 at 7:44 P.M., nurse contacted the physician regarding positive C-diff culture results. New order received to begin Vancomycin (antibiotic) 125 milligrams (mg) four times a day for ten days.
Review of the resident's electronic physician order sheet (ePOS), dated June 2019, showed an order dated 5/28/19 for Vancomycin (antibiotic) 125 milligrams (mg) per 2.5 milliliters (ml) give 125 mg four times a day for ten days for C-diff infection.
Further review of the resident's clinical notes, showed:
-On 5/28/19 at 9:14 A.M., the resident continues to have foul smelling liquid stools throughout the shift. The resident has started ordered antibiotic for C. diff;
-On 5/29/19 at 8:51 A.M., the resident remained on antibiotic for C. diff infection. No adverse reactions noted.
Further review of the resident's ePOS, showed an order dated 5/29/19 for Vancomycin 125 mg per 2.5 ml, increase dose to 250 mg four times a day for ten days for C-diff infection.
Review of the resident's care plan, dated 5/30/19, showed:
-Problem: The resident is receiving antibiotics related to a C-diff infection;
-Goal: Staff assess for signs and symptoms of infection;
-Interventions: Staff assess the resident for changes in mental status related to worsening infection, assess and document skin for changes, assess the resident's temperature, monitor the resident's weight, monitor laboratory values and notify and consult with the physician for any changes, follow standard and transmission based precautions;
-The care plan did not specify the type of transmission based precautions to be used (standard, contact, droplet, or airborne).
Further review of the resident's clinical notes, showed on 6/2/19 at 10:31 A.M., the resident remained on antibiotics for C- diff infection.
Observation and interview during the survey, showed:
-On 6/5/19:
-At 11:30 A.M., the resident said he/she had been in the facility for a few weeks and taking antibiotics. He/she had loose stools often and staff helped to give him/her care. Observation at this time, showed no signage or personal protective equipment (PPE, gloves, masks, gowns, etc.) noted outside of the resident's room;
-At 2:01 P.M., the resident lay asleep in bed. No signage or PPE supplies outside of the resident room;
-On 6/6/19 at 7:09 A.M., no contact precaution sign noted on or near the resident's room door, no PPE supplies noted to be accessible to staff or visitors outside the room.
Further review of the clinical notes, showed
-On 6/6/19 at 1:46 P.M., new orders to continue Vancomycin dosing extended through 6/11. Dose remains the same, 250 mg four times a day.
-On 6/6/19 at 2:09 A.M., resident remains on Vancomycin for c-diff.
Continued observations during the survey, showed:
-On 6/6/19 at 7:10 A.M., 11:10 A.M., 1:09 P.M., and 2:22 P.M., no PPE supplies outside of the room and no isolation or contact precautions notification on or near the door;
-On 6/7/19 at 6:45 A.M. and 7:48 A.M., mo isolation or contact precautions notification on the outside of the resident's room. No PPE supplies for staff or visitors noted near the resident's doorway;
-At 9:16 A.M., the resident in the hallway working with therapy;
-At 1:22 P.M., the resident in his/her room watching television. No isolation or contact precaution notification or PPE supplies for staff and visitors near the resident's doorway;
-On 6/10/19 at 10:42 A.M., 2:01 P.M., and 4:45 P.M., no isolation or contact precautions notification outside of the resident's room door and no PPE supplies available to staff or visitors;
-On 6/11/19 at 7:33 A.M., the resident awake in bed and watched television. No isolation or contact precaution notification or PPE supplies for staff and visitors near the resident's doorway.
During an interview on 6/11/19 at 9:22 A.M., Certified Medication Technician (CMT) J said the resident was taking Vancomycin for C-diff. The resident had been on precautions about a week and a half ago. He/she had not been notified if the resident's contact precautions had been lifted. He/she assumed since the supplies were gone that the resident had been cleared. He/she did not know if the resident had been cleared of the infection.
During an interview on 6/11/19 at 9:26 A.M., Licensed Practical Nurse (LPN) I said he/she had been working with the resident for about a week and the resident had been taking Vancomycin for C-diff infection. Since he/she had been working with the resident, there had been no contact precaution supplies outside of the room. He/she had been told by other nurses that the contact precautions had been lifted but he/she did not know if repeat testing had been performed.
During an interview on 6/11/19 at 9:25 A.M., Certified Nursing Assistant (CNA) K said he/she had worked with the resident for several weeks. A few weeks ago, he/she had been told that the resident had C-diff and had contact precaution supplies outside of the room. When he/she came back to work a week ago, the precautions supplies had been removed and the other CNA told him/her the precautions had been lifted. The resident has been having loose stools a lot.
During an interview on 6/11/19 at 9:40 A.M., LPN I said he/she did not know the resident had been having loose stools. The resident should be considered contagious until he/she had solid stools for several days and a repeat lab test showed the C-diff as colonized. He/she would need to contact the physician. The resident is scheduled to stop the Vancomycin in a few days.
During an interview on 6/11/19 at 9:59 A.M., the Assistant Director of Nursing (ADON) said if a resident is being treated for C-diff, the resident should remain on contact precautions until the administration of antibiotics is completed and symptoms had resolved. If the resident is continuing to have symptoms, he/she should be considered contagious.
During an interview on 6/11/19 at 12:07 P.M., the administrator said he and the nurse manager had reviewed the resident's medical record and it appeared that when the Vancomycin order continued for additional days, the contact precautions were accidentally removed. The resident should have remained on contact precautions for the entire time while receiving Vancomycin. The staff are placing contact precaution supplies back in place now.
2. Review of the facility's administering medication policy, revised on 9/25/18, showed:
-Statement: Medication shall be administered in a safe manner;
-Staff shall follow established community infection control procedures for the administration of medications, as applicable.
Review of Resident #124's medical record, showed:
-admitted to the facility on [DATE];
-Diagnoses included pneumonia, respiratory failure and vascular disease;
-An order dated 5/29/19, for aspirin 325 mg delayed release, take one tablet daily.
Observation on 6/6/19 at 9:13 A.M., showed LPN I opened the stock bottle of aspirin EC (enteric coated, a protective coating that protects the stomach) and tipped the lip of the medication bottle over the medication cup. He/she used his/her bare finger, stuck his/her finger in the stock medication bottle, pulled a tablet from the bottle, placed the medication into the medicine cup and administered the medication to the resident.
During an interview on 6/6/19 at 9:30 A.M., LPN I said he/she did not realize he/she touched the tablet with his/her bare hand before placing the medication in the cup. Medications should not be handled with bare hands, but with a gloved hand.
During an interview on 6/6/19 at 10:01 A.M., the Director of Nursing said medications should never be handled with bare hands. If a medication needed to be touched, the staff should apply gloves and handle the medication.
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 prevent gnats in resident rooms for one resident (Resident #138). The sample was...
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Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent gnats in resident rooms for one resident (Resident #138). The sample was 28. The census was 205 with 140 residents in certified beds.
Review of Resident #138's quarterly Minimum Data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/12/19, showed the following:
-Moderate cognitive impairment;
-Two person staff assistance for bed mobility, toilet use and transfers;
-One person staff assistance for dressing, eating and personal hygiene;
-Upper extremity impairment on both sides;
-Lower extremity impairment on both sides;
-Mobility, wheelchair;
-Diagnoses included high blood pressure, multiple sclerosis (an autoimmune disease of the nervous system) and anemia.
Observation and interview of the resident on 6/05/19 at 10:22 A.M., showed the resident in his/her room. He/she lay in his/her bed, propped upright by pillows. Two drink cups with lids and drink spouts sat on the bedside table beside him/her, both drink spouts covered with gnats. Nurse R entered the room, removed the cups and returned with two filled cups. Nurse R said one of the cups was empty, so he/she got a new cup, and the other cup, he/she filled back up.
Observation on 6/11/19 at 7:16 A.M., showed the resident lay in bed, propped on his/her left side with pillows. Two drink cups with lids and drink spouts sat on the bedside table beside him/her, both drink spouts covered with gnats. He/she said the gnats were bothering him/her, they get on his/her cups and he/she does not want to drink from his/her cups.
During an interview on 6/11/19 at 8:34 A.M., Certified Nursing Assistant (CNA) T said whenever the weather gets warm, the gnats were bad. He/she tried to keep the room clean and was aware the gnats got on the resident's drinks.
During an interview on 6/11/19 at 8:37 A.M., Housekeeper S said he/she was aware of the gnats and they were bad in the resident's room.
During an interview on 6/11/19 at 8:42 A.M., the Assistant Director of Nursing (ADON) said he/she was not aware of gnats being a problem in the resident's room. There was a binder at each nurse's station for the pest control company, which records recent treatments and concerns.
Review of the Pest Control Binder on the third floor nurse's station, showed:
-On 2/21/19, bed bug inspection, reported by CNA;
-On 5/21/19, spider, treated room, reported by resident;
-No other documented pest control treatments.
During an interview on 6/11/19 at 12:43 P.M. the maintenance director said he was not aware of the gnats in the resident's room. He would expect staff to notify him of pests and place a note in the pest control binder of concerns on the floors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide written notice to the resident or their legal representative of the facility bed hold policy at the time of transfer to the hospita...
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Based on interview and record review, the facility failed to provide written notice to the resident or their legal representative of the facility bed hold policy at the time of transfer to the hospital for five of 28 sampled residents, who were recently transferred to the hospital for various medical reasons (Residents #67, #27, #138, #66 and #90). The census was 205 with 140 residents in certified beds.
1. Review of Resident #67's electronic medical record, showed:
-Discharge to the hospital on 3/29/19;
-Returned to the facility on 4/2/19;
-No documentation the resident and/or the representative received written notice of the facility's bed hold policy at the time of transfer.
2. Review of Resident #27's electronic medical record, showed:
-discharged to the hospital on 2/25/19;
-Returned to the facility from the hospital on 3/4/19;
-discharged to the hospital on 3/6/19;
-Returned to the facility from the hospital on 3/11/19;
-No documentation the resident and/or the representative received written notice of the facility's bed hold policy at the time of transfers.
3. Review of Resident #138's electronic medical record, showed:
-discharged to the hospital on 4/29/19;
-Returned to the facility from the hospital on 5/16/19;
-No documentation the resident and/or the representative received written notice of the facility's bed hold policy at the time of transfer.
4. Review of Resident #66's electronic medical record, showed:
-discharged to the hospital on 2/11/19;
-Returned to the facility from the hospital on 2/18/19;
-No documentation the resident and/or the representative received written notice of the facility's bed hold policy at the time of transfer.
5. Review of Resident #90's electronic medical record, showed:
-discharged to the hospital on 4/11/19;
-Returned to the facility from the hospital on 4/20/19;
-No documentation the resident and/or the representative received written notice of the facility's bed hold policy at the time of transfer.
6. During an interview on 6/7/19 at 2:10 P.M., the Director of Nurses said the facility bed hold policy is given to the resident and/or the representative upon admission to the facility. Facility staff had not been issuing any written notice of the facility's bed hold policy as required when a resident transferred to the hospital.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident receives adequate assistive devices to prevent accidents by failing to ensure a resident's electronic wheelchair had been charged and was available for use during transport to a scheduled appointment. The resident had a history of slipping out of the chair used in place of the electric wheelchair and this resulted in a fall during transportation. In addition, the facility failed to follow the safe medication storage policy when medications were left accessible, on top of a medication cart and in an unlocked nurse cart. These practices affected one of 28 sampled residents (Resident #66) and had the potential to affect all residents who could self-ambulate or self-propel on the halls where the medications were left accessible. The census was 205 with 140 residents in certified beds.
1. Review of the facility's Fall Policy, dated [DATE] and revised on [DATE], showed:
-Policy Statement: Based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling;
-Fall definition, an incident in which the resident unintentionally comes to rest on the ground, floor, or other lower level. A fall without injury is still a fall;
-If falling recurs, despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant;
-Event investigation form: Complete all applicable sections:
-What happened;
-Where it occurred;
-What injuries were incurred;
-Any resident statements;
-Any other factors or conditions believed to be relevant to the cause of the event.
Review of Resident #66's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following:
-Cognitively intact;
-Two person staff assistance for bed mobility and transfers;
-One person staff assistance for dressing, eating, toilet use and personal hygiene;
-Upper extremity impairment on both sides;
-Lower extremity impairment on both sides;
-Diagnoses included high blood pressure, obstructive uropathy (a condition in which the flow of urine is blocked) and diabetes.
Review of the resident's physician order sheet (POS), dated [DATE] through [DATE], showed a treatment order, dated [DATE], for resident to receive dialysis (process of filtering toxins from the blood in individuals with kidney failure) on Tuesday, Thursday, and Saturday. Resident to be ready by 4:30 A.M.
Review of the resident's care plan, in use during the survey, showed:
-Problem: Dialysis/Renal (kidney) failure, has the potential for complications related to dialysis for diagnosis of renal failure:
-Goal: Remain free from complications related to renal dialysis;
-Interventions: Make transportation arrangements for dialysis.
-Goal: Will not experience a decline in activities of daily living (ADL) functions:
-Interventions: Assist with ADL's, fostering independence. Assist with mobility as necessary or as requested by the resident;
-Problem: At risk for falls related to decreased function:
-Goal: Will remain free from falls;
-Interventions: Documented sliding falls from wheelchair on [DATE] (resident will be fitted for a wheelchair) and [DATE], a piece of Dycem (a no-slip, rubber-like plastic material used to stabilize) was applied to wheelchair seat to help prevent him/her from slipping. On [DATE], resident slid out of chair. Physical therapy (PT)/occupational therapy (OT) to evaluate for chair positioning.
Review of the resident's medical record, showed no order for a physical therapy/occupational therapy evaluation following the fall on [DATE].
Review of the facility Accident/Incident Report, dated [DATE], showed at 1:00 P.M., showed the nurse received a call from the van driver saying the resident had slid out of his/her wheelchair in the van. A call was placed to the transportation company to discuss driver's skill.
Review of the facility Adverse Event Documentation, dated [DATE], showed:
-Clinical event: Fall. Description of event (include resident/client/patient statements): The nurse got a call from the driver saying the resident had slid out of his/her wheelchair in the van;
-What happened: Slid out of wheelchair while on transport van. Chair was strapped down;
-Why: Driver breaking hard, occurred two times. Complaint taken, given to supervisor. Improve skills. Call will be placed if this occurs again;
-Action taken, call placed to company to report driver's skills. Driver to receive training. Resident will report if this happens again. New driver will be requested;
-Final action taken, driver training, resident to report if driver displays bad skills. Continue current fall precautions;
-Final determination, drivers skills caused resident to slide out of chair. Fall interventions were in place;
-No documented resident statement included per the facility Fall Policy;
-No reference to the resident's electric wheelchair not being charged and available prior to dialysis.
Review of the resident's progress notes, showed:
-On [DATE], at 11:00 P.M. through 7:00 A.M. shift, no new orders. At 12:00 A.M., the resident remains on follow up for a recent fall in the transport van coming back from dialysis on Saturday, [DATE]. No injuries, the physician was made aware by day nurse, and a call was placed to the responsible party. The resident was in his/her regular wheelchair, not the electric one since it was low battery. The resident has history of sliding out of regular wheelchairs;
-On [DATE], the resident continues post follow up for fall out of wheelchair. Up in electric wheelchair roaming around facility without any issues or complaints.
During an interview on [DATE] at 11:33 A.M., the physical therapy director said he had not received an order for a PT/OT evaluation as noted on the resident's care plan. He was aware of the resident's fall, but was not aware the electric wheelchair was not working on the day of dialysis due to a dead battery. The resident's electric wheelchair battery should be checked by staff and they should ensure the wheelchair is available for the resident's use.
During interview on [DATE] at 3:46 P.M., the resident said he/she slid out of the wheelchair when the van stopped quickly. Staff forgot to plug his/her electric wheelchair in and the battery had died. He/she had to take a regular wheelchair and he/she has difficulty sitting up in a regular wheelchair. He/she liked the electric wheelchair because it has an attached seatbelt which he/she used while traveling for extra security.
During an interview on [DATE] at 6:39 A.M., Nurse Q said the resident had difficulty sitting in a regular wheelchair, even with the attachment used to prevent his/her sliding forward. The resident's electric wheelchair was inoperable on the morning of dialysis because staff failed to plug the battery in overnight. The certified nursing assistant (CNAs) who provided care for the resident should have plugged in the battery when the resident went to bed and ensured the wheelchair was fully charged for the following days use.
During an interview on [DATE] at 2:45 P.M., the Assistant Director of Nursing (ADON) said the facility investigated the incident and the facility concluded the responsibility of the fall was due to the van driver stopping abruptly.
2. Review of the facility's storage of medication policy, dated [DATE], showed:
-Statement: The community shall store all drugs and biologicals in a safe, secure, and orderly manner;
-Interpretation and implementation:
-Compartments including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes containing drugs and biologicals shall be locked when not in use, and trays or carts that transport such items should not be left unattended if open or otherwise potentially available to others;
-Drugs shall be stored in an orderly manner in cabinets, drawers, or carts;
-Only persons authorized to prepare and administer medications shall have access to the medication.
Observations on [DATE], of the [NAME] Street medication cart and the nurse treatment cart, showed:
-At 6:45 A.M., One unopened medication card of Januvia (used to treat diabetes) 100 milligram (mg) 15 tablets and one card of Remeron (used to treat depression) 15 mg that contained 15 tablets lay exposed and unsecured on top of the [NAME] Street medication cart. No nurse or certified medication technician (CMT) present. One CNA observed charting at a table in the hallway. The [NAME] street Nurse treatment cart was unlocked. The nurse treatment cart's top drawer contained two insulin pens and approximately 20 disposable pen needles, two vials of intramuscularly injectable Lasix (used to treat swelling), 10 bottles of various stock medications, three vials of intramuscular B-12 vitamin injections. The middle drawer contained three gallon sized bags of lidocaine (used to treat pain) pain patches;
-At 7:01 A.M., Licensed Practical Nurse (LPN) B walked past the medication cart. He/she did not address the two exposed medication cards on top of the cart or lock the nurse cart;
-At 7:05 A.M., two CNAs walked past the medication cart and unsecured nurse cart. The staff did not notify the nurse of the exposed medication on top of the cart;
-At 7:08 A.M., a resident propelled himself/herself past both the unlocked nurse cart and the medication cart. The two medication cards continued to lay exposed on top of the cart.
During an observation and interview on [DATE] at 7:15 A.M., LPN D said medications should never be left on top of a medication cart and accessible to residents. LPN D removed the two medication cards from the top of the medication cart. All medication and treatment carts should be locked and secured unless in use by staff. The carts should be locked any time staff are away from the carts.
During an observation and interview on [DATE] at 7:20 A.M., LPN B said he/she worked the night shift on [DATE] and preformed the narcotic count on the unlocked nurse cart when he/she started the shift. He/she did not need to access the nurse cart during his/her night shift and must have left the nurse cart unlocked for the entire night shift. He/she had been unaware the nurse cart had been unlocked. He/she had been responsible for the nurse cart and the medication cart. He/she had not been aware of the two medication cards on top of the medication cart and did not know how long the medication lay accessible to residents.
During an interview on [DATE] at 8:35 A.M., the ADON said medications should not be left accessible and unsecured. Medication and nurse treatment carts should always be locked and secured. Leaving medications accessible and facility carts unlocked is unsafe.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 18 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $19,460 in fines. Above average for Missouri. Some compliance problems on record.
Bottom line: Mixed indicators with Trust Score of 71/100. Visit in person and ask pointed questions.
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About This Facility
What is Mason Pointe's CMS Rating?
CMS assigns MASON POINTE CARE CENTER an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Missouri, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Mason Pointe Staffed?
CMS rates MASON POINTE CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 45%, compared to the Missouri average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Mason Pointe?
State health inspectors documented 18 deficiencies at MASON POINTE CARE CENTER during 2019 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 17 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Mason Pointe?
MASON POINTE CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by EVERTRUE, a chain that manages multiple nursing homes. With 127 certified beds and approximately 41 residents (about 32% occupancy), it is a mid-sized facility located in CHESTERFIELD, Missouri.
How Does Mason Pointe Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, MASON POINTE CARE CENTER's overall rating (5 stars) is above the state average of 2.5, staff turnover (45%) is near the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.
What Should Families Ask When Visiting Mason Pointe?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Mason Pointe Safe?
Based on CMS inspection data, MASON POINTE CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 5-star overall rating and ranks #1 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 Mason Pointe Stick Around?
MASON POINTE CARE CENTER has a staff turnover rate of 45%, which is about average for Missouri nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Mason Pointe Ever Fined?
MASON POINTE CARE CENTER has been fined $19,460 across 1 penalty action. This is below the Missouri average of $33,273. 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 Mason Pointe on Any Federal Watch List?
MASON POINTE CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.