JACKSON CREEK POST ACUTE
For profit - Limited Liability company
120 Beds
NATIONAL HEALTHCARE CORPORATION
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
28/100
#253 of 479 in MO
Photo by Jackson Creek Post Acute
Photo by Jackson Creek Post Acute
Photo by Jackson Creek Post Acute
1 / 5 photos
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Jackson Creek Post Acute has received a Trust Grade of F, indicating poor performance and significant concerns about the care provided. With a state rank of #253 out of 479 facilities in Missouri, they fall in the bottom half, and they are ranked #16 out of 38 in Jackson County, showing that only a few local options are better. Although the facility is trending toward improvement, as issues have decreased from 15 in 2024 to 4 in 2025, they still have concerning incidents, including a critical case where a resident did not receive scheduled dialysis, resulting in a severe health crisis. Staffing is a relative strength, with a turnover rate of 55%, which is below the state average, but the facility has less RN coverage than 86% of Missouri facilities, raising concerns about adequate nursing oversight. Additionally, while the fines of $27,560 are average, they highlight ongoing compliance issues that families should consider when evaluating care options.
- Trust Score
- F
- In Missouri
- #253/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $27,560 in fines. Higher than 85% of Missouri facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 15 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Bottom 48%
Review needed
15 → 4 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 15 issues
2025: 4 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Missouri average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 55%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Federal Fines: $27,560
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: NATIONAL HEALTHCARE CORPORATION
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 34 deficiencies on record
1 life-threatening 1 actual harm
Apr 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to notify one sampled resident's (Resident #1) physician of the resident's refusal of his/her dialysis medication and late admini...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to notify one sampled resident's (Resident #1) physician of the resident's refusal of his/her dialysis medication and late administration of the resident's sliding scale insulin, out of seven sampled residents. The facility census was 99 residents.
Review of the facility Change in a Resident Condition or Status policy dated 2001 showed:
-The facility was to promptly notify the resident's attending physician of changes in the resident's medical/mental condition and/or status.
-The licensed nurse would notify the resident's attending physician or physician on call when a resident refused treatment or medications at least two consecutive times.
1. Review of Resident #1's Physician's Orders Sheet (POS) dated April 2025 showed:
-Diagnoses of end stage renal disease, dependence on renal dialysis, and diabetes.
-Insulin Lispro (a fast-acting insulin that starts to work about 15 minutes after injection, has its most significant effect on lowering blood sugar levels in about 1 hour, and keeps working for 2 to 4 hours) Subcutaneous (under the skin) solution cartridge 100 units/milliliter (ml) inject per sliding scale (a method to determine how much insulin to give based on a person's current blood sugar) including for a blood sugar of 401 to 450 give 12 units after meals.
-Sevelamer (medication used to control high blood levels of phosphorus in people who are on dialysis) 800 milligrams (mg), give two tablets with meals for dialysis.
Observation and interview with the resident on 4/8/25 at 12:35 P.M. showed:
-The resident had finished eating his/her lunch.
-He/she said he/she was to take two large capsules with each meal, and no one had brought in that medication.
During an interview on 4/8/25 at 2:07 P.M. Certified Medication Technician (CMT) A said:
-The resident was very emotional that morning and had refused to take his/her Sevelamer with his/her breakfast.
-He/she knew the resident would not take the Sevelamer at lunch because he/she had refused it at breakfast.
-He/she did not offer the Sevelamer to the resident with the resident's lunch.
-He/she marked that the resident had taken the Sevelamer at breakfast and at lunch.
-He/she had not told the charge nurse that the resident had refused the Sevelamer at breakfast and had not told the charge nurse that he/she had not offered the Sevelamer to the resident with his/her lunch meal.
-He/she knew the medication the resident was to take with meals was very important for him/her to take.
-The resident was often emotional and usually did not take the Sevelamer for him/her and he/she would document that he/she had given the medication to the resident.
-He/she knew he/she should tell the charge nurse if a resident refused a medication or if he/she did not give a resident a medication to a resident.
During an interview on 4/8/25 at 2:55 P.M. Agency Registered Nurse (RN) A said:
-He/she had not done the resident's lunch time blood glucose monitoring (the test system includes a handheld meter and test strips to measure how much glucose is in a small sample of blood) and had not administered any sliding scale insulin to the resident after his/her lunch meal.
-He/she had not had time to talk to anyone about the resident's lunch time blood glucose monitoring and sliding scale insulin.
-CMT A had not told him/her that the resident had refused his/her Sevelamer with breakfast or that he/she had not given the resident his/her Sevelamer with lunch.
During an interview on 4/10/25 at 3:16 P.M. Nurse Unit Manager A said:
-The resident's physician should have been notified when the resident refused or did not receive medications.
-He/she did not see progress notes that the resident's physician had been notified regarding any refused or missed medications.
-If a resident did not receive a medication, it was to be documented correctly on the resident's Medication Administration Record (MAR), there were codes for showing reasons a medication was not administered.
-The resident's MAR showed his/her 4/8/25 after lunch sliding scale insulin was administered at 3:44 P.M.; there was no progress note that the resident's physician had been notified.
During an interview on 4/10/25 at 3:50 P.M. the Director of Nursing (DON) said:
-The CMT should have told the charge nurse, or the Unit Manager that the resident had refused medications.
-Then the charge nurse or the Unit Manager should have notified the resident's physician the resident had refused or did not receive medications.
-Agency RN A should have told the Unit Manager that he/she had missed administering the resident's after lunch sliding scale insulin.
-Either Agency RN A or the Unit Manager should have notified the resident's physician that the resident's after lunch sliding scale insulin had not been done after his/her lunch and these were not done until later that afternoon that way the resident's physician could decide if he/she wanted to give any additional orders.
MO00252435
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure one sampled resident's (Resident #1) refusal of medications, omission of and late administration of medications was cor...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure one sampled resident's (Resident #1) refusal of medications, omission of and late administration of medications was correctly documented and communicated to facility management; and failed to revise the resident's care plan to address the resident's refusal of medications, out of seven sampled residents, and failed to have a policy to address sliding scale insulin. The facility census was 99 residents.
Review of the facility Insulin Administration policy dated 2001 showed:
-Rapid-acting insulin has an onset of 10-15 minutes, a peak of 30 minutes to one hour and a duration of 3-6 hours.
-The policy did not address sliding scale insulin.
Review of the facility Administering Medications policy dated 2001 showed:
-Medications are administered in accordance with prescriber orders, including any required time frame.
-Medication administration times are determined by resident need including enhancing optimal therapeutic effect of the medication.
-Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
1. Review of Resident #1's Physician's Orders Sheet (POS) dated April 2025 showed:
-Diagnoses of end stage renal disease, dependence on renal dialysis, and diabetes.
-Insulin Lispro (a fast-acting insulin that starts to work about 15 minutes after injection, has its most significant effect on lowering blood sugar levels in about 1 hour, and keeps working for 2 to 4 hours) Subcutaneous (under the skin) solution cartridge 100 units/milliliter (ml) inject per sliding scale (a method to determine how much insulin to give based on a person's current blood sugar) including for a blood sugar of 401 to 450 give 12 units after meals.
-Sevelamer (medication used to control high blood levels of phosphorus in people who are on dialysis) 800 milligrams (mg), give two tablets with meals for dialysis.
Observation and interview with the resident on 4/8/25 at 12:35 P.M. showed:
-The resident had finished eating his/her lunch.
-He/she said he/she was to take two large capsules with each meal, and no one had brought in that medication.
During an interview on 4/8/25 at 1:58 P.M. the resident said:
-No one had checked his/her blood sugar, and no one had given him/her any insulin after his/her lunch meal and also had never given him/her the two capsules that he/she was to take with his/her lunch.
-He/she had not been taking the large binder capsules because of an increase in the dose to three capsules with meals, that was too much to swallow, but the dose had recently been changed to two capsules and he/she had decided he/she would take it, but no one brought the medication to him/her at lunch.
During an interview on 4/8/25 at 2:07 P.M. Certified Medication Technician (CMT) A said:
-The resident was very emotional that morning and had refused to take his/her Sevelamer with his/her breakfast.
-He/she knew the resident would not take the Sevelamer at lunch because he/she had refused it at breakfast.
-He/she did not offer the Sevelamer to the resident with the resident's lunch.
-He/she marked that the resident had taken the Sevelamer at breakfast and at lunch.
-He/she had not told the charge nurse that the resident had refused the Sevelamer at breakfast.
-He/she had not told the charge nurse that he/she had not offered the Sevelamer to the resident with his/her lunch meal.
-He/she knew the medication the resident was to take with meals was very important for him/her to take.
-The resident was often emotional and usually did not take the Sevelamer for him/her and he/she would document that he/she had given the medication to the resident.
-He/she knew he/she should tell the charge nurse if a resident refused a medication or if he/she did not give a resident a medication to a resident.
-He/she knew that he/she should not document that he/she gave a medication that had not been given.
During an interview on 4/8/25 at 2:55 P.M. Agency Registered Nurse (RN) A said:
-He/she had not done the resident's lunch time blood glucose monitoring (the test system includes a handheld meter and test strips to measure how much glucose is in a small sample of blood) and had not administered any sliding scale insulin to the resident after his/her lunch meal.
-He/she had not had time to do the resident's blood glucose monitoring because of other resident care he/she had been doing.
-He/she had not had time to talk to anyone about the resident's lunch time blood glucose monitoring and sliding scale insulin.
-CMT A had not told him/her that the resident had refused his/her Sevelamer with breakfast or that he/she had not given the resident his/her Sevelamer with lunch.
During an interview on 4/8/25 at 3:05 P.M. Unit Nurse Manager A said:
-He/she was not aware the resident had not had his/her Sevelamer with his/her breakfast and lunch.
-CMT A should have told the charge nurse, or him/her that the resident refused his/her breakfast dose of Sevelamer.
-Agency RN A had not told him/her that he/she had not done the resident's after lunch blood glucose monitoring and sliding scale insulin.
-He/she had been available and could have helped RN A if he/she had notified him/her that he/she needed help.
-The resident's blood glucose monitoring and sliding scale insulin should have been completed as soon as possible after he/she finished his/her lunch.
-The resident's lunch was typically served by noon.
During an interview on 4/10/25 at 2:25 P.M. the Care Plan Coordinator said:
-He/she had not previously known that the resident sometimes refused his/her dialysis medications, and the residents care plan had not addressed refusal of medications.
-The resident's care plan should have addressed the refusal of medications.
During an interview on 4/10/25 at 3:16 P.M. Nurse Unit Manager A said:
-If a resident did not receive a medication, it was to be documented correctly on the resident's Medication Administration Record (MAR), there were codes for showing reasons a medication was not administered.
-CMT A had documented that the resident's Sevelamer had been given at breakfast and at lunch on 4/8/25.
-CMT A should have correctly documented the resident did not take the medication and the reason.
-Any refusal of his/her medications needed to have been communicated to him/her and the care plan coordinator so the resident's care plan would address his/her refusal of medications.
-The resident's MAR showed his/her 4/8/25 after lunch sliding scale insulin was administered at 3:44 P.M.
-The resident's noon meal sliding scale should have been given as close to him/her finishing his/her lunch meal as possible.
During an interview on 4/10/25 at 3:50 P.M. the Director of Nursing (DON) said:
-The CMT should have correctly documented the resident had not taken medications and the reason the resident did not take the medications.
-The CMT should have told the charge nurse or the Unit Manager that the resident had refused medications.
-The resident's after meal blood glucose monitoring and sliding scale insulin should have been completed as close to the end of his/her meal as possible.
-The licensed nurse should have told the Unit Manager that he/she had missed administering the resident's after lunch blood glucose monitoring and sliding scale insulin.
MO00252435
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure communication between the facility and dialysis (a procedure that uses a machine to filter blood when the kidneys were no longer abl...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure communication between the facility and dialysis (a procedure that uses a machine to filter blood when the kidneys were no longer able to do so) provider to provide coordinated and consistent care for one sampled resident (Resident #1) with end stage renal disease (permanent kidney failure that requires a regular course of dialysis) out of seven sampled residents. The facility census was 99 residents.
Review of the facility End-Stage Renal Disease policy dated 2021 showed:
-The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.
-There would be communication between the dialysis clinic and the facility.
1. Review of Resident #1's Physician's Orders Sheet (POS) dated April 2025 showed:
-Diagnoses of end stage renal disease, dependence on renal dialysis.
-Dialysis Monday, Tuesday, Wednesday and Friday.
During an interview on 4/9/25 at 2:20 P.M. the resident's dialysis clinic nurse said:
-For about two months there had been no written communication between the facility before or after the resident's dialysis.
-The facility had not provided a form for the dialysis clinic to provide information to the facility regarding the resident's dialysis treatments.
-The facility also had not called the facility to get a verbal report regarding the resident's dialysis treatments.
During an interview on 4/9/25 at 2:50 P.M. Licensed Practical Nurse (LPN) B said:
-There used to be a paper that came back with the resident from dialysis but for at least four weeks there had been not written communication returned from his/her dialysis appointments.
-He/she had not called the resident's dialysis provider to get a report on the resident and to ask that the dialysis provider send a written report back to the facility with the resident.
During an interview on 4/10/25 at 1:40 P.M. the resident said:
-Facility nurses put a form in a bag on the back of his/her wheelchair with his/her weight and vital signs.
-The dialysis nurses had stopped looking in his/her bag for the form and he/she had gotten tired of telling them to get the form out of his/her bag a couple of months ago.
-The dialysis nurses hadn't given any information back to the facility after his/her dialysis treatments for a long time.
-He/she had gotten tired of telling everyone about the form and stopped saying anything about the dialysis papers.
During an interview on 4/10/25 at 3:50 P.M. the Director of Nursing (DON) said:
-He/she expected licensed nurses to fill out and send a report sheet with the resident to his/her dialysis appointments.
-He/she expected licensed nurses to print a sheet for the dialysis provider to use an provide a written report back to the facility following dialysis.
MO00252435
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure infection control measures when applying a dressing over one sampled resident's (Resident #1's) central venous catheter...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure infection control measures when applying a dressing over one sampled resident's (Resident #1's) central venous catheter (CVC - a tube inserted into a large vein, often in chest, or groin, and used for various purposes, including hemodialysis - dialysis a procedure that uses a machine to filter blood when the kidneys were no longer able to do so), out of seven sampled residents. The facility census was 99 residents.
Review of the facility Central Venous Catheter Care and Dressing Changes policy dated 2001 showed:
-The purpose of the procedure was to prevent associated complications including catheter-related infections associated with contaminated (exposed to germs, bacteria, or other foreign particles), loosened, soiled (dirty, regardless of the source of the dirt), or wet dressings.
-Perform site care and dressing change immediately if the integrity of the dressing is compromised- damp loosened or visibly soiled.
-Open sterile dressing kit.
-Apply mask.
-Apply sterile gloves.
-Clean catheter insertion site with approved antiseptic solution.
-Apply sterile dressing.
Review of the facility Enhanced Barrier Precautions (EBPs - extended use of infection control measures that extends use personal protective equipment - PPE, like gowns and gloves) policy dated 2001 showed:
-EBPs are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDRO) to residents.
-EBPs employ targeted gown and glove use in addition to standard precautions (basic infection prevention practices used in healthcare settings for all patients, regardless of their suspected or confirmed infection status) during high contact resident care activity, including central line care.
Review of the Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, QSO-24-08-NH, posting date - effective date 4/1/24 showed:
-CMS issued new guidance for long term care (LTC) facilities on the use of (EBP) to align with nationally accepted standards.
-EBP recommendations now include use of EBP for residents with indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status.
-For residents for whom EBP are indicated, EBP is employed when performing central line care.
1. Review of Resident #1's care plan dated 2/4/25 showed:
-He/she required hemodialysis related to end stage renal failure and had an implanted port to his/her right chest.
-His/her dialysis center was to provide dialysis catheter access site care.
-May change the dressing if it became soiled or fell off.
Review of the resident's Physician's Orders Sheet (POS) dated April 2025 showed:
-Diagnoses of end stage renal disease and dependence on renal dialysis.
-Change central line dressing every seven days and as needed for infection prevention and accidental dressing removal.
Observation on 4/8/25 at 2:05 P.M. showed:
-Unit Nursing Manager A entered the resident's room without first putting on a gown or mask, put a prepackaged dressing on a surface without first putting a barrier (a disposable cover placed on frequently touched surfaces to prevent contamination and reduce the need for frequent cleaning and disinfection), washed his/her hands and put the gloves.
-He/she then picked up the packaged dressing, opened the dressing and without first cleansing the resident's dialysis access site on his/her right chest applied an adhesive dressing over the resident's dialysis site.
Observation on 4/9/25 of the contents of the facility Central Line Dressing Kit showed the kit included:
-Two masks.
-Gloves.
-Alcohol wipe.
-Dressing.
During an interview on 4/9/25 Nurse Manager B said:
-The Central Line Dressing Kits had two masks.
-One of the masks was for the nurse and one was for the resident to use during the dressing change.
During an interview on 4/10/25 at 2:10 P.M. Unit Nurse Manager A said:
-He/she should have cleansed the resident's central line site before applying the dressing.
-He/she should have worn a mask and gown.
-He/she should have used a barrier for the resident's dressing before placing it on a surface.
-He/she could have reached out to see if there was a central line dressing kit on the other nursing unit.
During an interview on 4/10/25 at 3:50 P.M. the Director of Nursing (DON) said:
-He/she expected licensed nurses to follow EBP, when having direct contact with dialysis residents.
-When applying dressings to central lines he/she expected the licensed nurses to wear the appropriate PPE that included a mask and gown and to provide a mask for the resident.
-He/she expected all residents with central lines to have their own Central Line Dressing Kit available.
-If a resident did not have a Central Line Dressing Kit, he/she expected the licensed nurse to reach out to other nurses to see if a kit was available.
-A barrier should be used for any supplies used for dressing changes.
-The resident's central line insertion site should have been cleansed with an alcohol wipe prior to application of the new dressing.
MO00252435
Oct 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0698
(Tag F0698)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one sampled resident (Resident #1) who required dialysis th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one sampled resident (Resident #1) who required dialysis three times a week, received physician ordered dialysis services on 10/22/24 and 10/24/24. On 10/26/24, the resident was sent to dialysis and dialysis staff noticed a significant change in condition and sent the resident to the hospital. The resident was admitted to the hospital on [DATE] for weight gain, abdominal pain, acute encephalitis (a neurological condition), end stage renal disease, hyponatremia (low sodium), hyperkalemia (elevated potassium), and his/her hemoglobin was low- requiring an immediate blood transfusion before the resident could receive dialysis. The facility census was 91 residents.
The Administrator was notified on 10/29/24 at 3:38 P.M., of an Immediate Jeopardy (IJ) which began on 10/26/24. The IJ was removed on 10/30/24 as confirmed by surveyor onsite verification.
Review of the facility's Care of a Resident with End-Stage Renal Disease Policy, dated September 2010, showed:
-Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.
-Education and training of staff in the care of ESRD/dialysis residents may be managed by the contracted dialysis facility or by a clinician with special training in ESRD and dialysis care.
-Agreement between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed.
-The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.
Review of the Coordination of Care Policy, dated 5/20/24, showed:
-The Purpose of the policy was to establish a framework for effective coordination of care for the residents in the facility.
-The policy aims to enhance communication among interdisciplinary team members, ensure continuity of care, and improve health outcomes for residents.
-Upon admission, a comprehensive assessment of each resident's medical, physical, emotional, and social needs will be conducted by the interdisciplinary team.
-Regular interdisciplinary (IDT) team meetings will be held at least weekly to discuss resident care plans, progress, and any necessary adjustments to treatment.
-The IDT will regularly monitor the resident's progress toward care plan goals.
-Staff member will receive training on the principles of care coordination, effective communication, and the roles of different team members in the coordination process.
-Feedback from residents, families, and staff will be solicited to enhance care coordination efforts continually.
Review of the facility Transportation Policy, dated 10/1/22, showed the facility will contract with licensed medical transportation vendors for the purpose of transporting patients, either by wheelchair or stretcher, for admission, to and medical appointments or to and from dialysis.
Review of the facility's undated Admissions Coordinator (Director) job responsibilities showed:
-Responsible for managing the admissions process for new residents and ensuring a smooth transition into the facility.
-Would involve coordinating with prospective residents, their families, and healthcare providers to facilitate the admission process.
-Responsibilities include helping communicate and install transportation schedules and norms for the facility and ensuring compliance with all regulatory requirement relation to admission and documentation.
1. Review of Resident #1's admission Record showed the resident readmitted on [DATE], with diagnoses including ESRD, chronic kidney disease, and dependence on renal dialysis.
Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 8/1/24, showed the resident severely cognitively impaired.
Review of the resident's undated Care Plan showed:
-The resident had a diagnosis of ERSD and was on dialysis Tuesday, Thursday and Saturday at the dialysis center, chair time from 6:30 A.M. to 10:00 A.M.
-Monitor hemodialysis (a medical procedure that filters a patient's blood to remove waste and excess fluid when their kidneys are no longer functioning properly) access site for signs and symptoms of complications and report abnormal findings to physician and/or dialysis center.
-Dialysis: Resident required hemodialysis related to end stage renal failure and was at risk for deficient/excess fluid volume, edema (swelling), high blood pressure and infection.
Review of the resident's Nurse's Note, dated 10/20/24 at 3:30 P.M., showed the resident readmitted from the hospital with no medication changes, continue current level of care.
Review of the resident's Order Summary Report for October 2024 showed:
-Dialysis: Complete observation tab, print and send with patient to dialysis, also collect once patient returns and place in the medical records bin to be scanned to the patient chart, one time a day every Tuesday, Thursday and Saturday for dialysis, ordered 4/26/24.
-Dialysis Center days and times of treatment, Tuesday, Thursday, and Saturday and name of transportation, ordered 4/30/24.
-Dialysis pre weight one time a day every Tuesday, Thursday and Saturday, ordered 4/26/24.
-Dialysis post weight one time a day every Tuesday, Thursday and Saturday, ordered 4/26/24.
Review of the resident's Treatment Administration Record (TAR) for October 2024 showed:
-Dialysis: Complete observation tab, print and send with patient to dialysis, also collect once patient returns and place in the medical records bin to be scanned to the patient chart, one time a day every Tuesday, Thursday and Saturday for dialysis- not documented as completed on 10/22/24.
-Dialysis Center days and times of treatment, Tuesday, Thursday, and Saturday and name of transportation, resident was to be picked up at 5:45 A.M. by a third party transportation company on dialysis days.
-Dialysis pre weight one time a day every Tuesday, Thursday and Saturday- not documented as completed on 10/22/24.
-Dialysis post weight one time a day every Tuesday, Thursday and Saturday- documented as other, see nurse's notes on 10/22/24 and 10/24/24.
Review of the resident's Nurse's Note, dated 10/22/24 at 2:04 P.M., showed dialysis post weight one time a day every Tuesday, Thursday, and Saturday for weight- no additional notes and signed by Licensed Practical Nurse (LPN) A.
Review of the resident's Nurse's Note, dated 10/24/24 at 8:15 P.M., showed dialysis post weight one time a day every Tuesday, Thursday and Saturday for weight- patient did not go to dialysis and signed by LPN A.
Review of the resident's Neurological Assessment Flow Sheet, dated 10/26/24, showed facility staff documented resident's blood pressure (B/P) as 211/92 (120/80 normal) on 10/26/24 at 4:15 A.M., pupil assessment normal, and hand grasps were greater on the left than the right. Resident transferred to the hospital from dialysis on 10/26/24, signed by the Unit Manager.
Review of the resident's Nurse's Note, dated 10/26/24 at 10:50 A.M., showed the resident left for dialysis at this time transported by a third-party transport company, signed by LPN A.
Review of the resident's Nurse's Note, dated 10/26/24 at 7:09 P.M., showed:
-Resident transferred from dialysis this morning to the hospital.
-Resident admitted to the hospital for elevated potassium and low hemoglobin.
-Family aware.
During an interview on 10/29/24 at 10:47 A.M., Hospital Registered Nurse (RN) A said:
-The resident was admitted to the hospital on [DATE] with weight gain, abdominal pain, acute encephalitis, ESRD, anemia, and hyponatremia.
-The resident received a transfusion due to low hemoglobin, before receiving dialysis on 10/26/24.
-The resident received dialysis on 10/26/24 and 10/27/24.
-There were additional complications on 10/29/24 and the resident was unable to receive dialysis.
During an interview on 10/28/24 at 4:03 P.M., LPN A said:
-He/She was the charge nurse for the resident on 10/22/24. He/She knew the resident did not go to dialysis on 10/22/24.
-He/She spoke to the dialysis center on 10/22/24 and was told it was too late for the resident to go to dialysis and to resume on the next scheduled dialysis day, 10/24/24.
-He/She did not notify or report to anyone the resident had missed dialysis on 10/22/24.
-Admissions or Social Services usually set up transportation for dialysis.
-He/She was the charge nurse for the resident on 10/24/24.
-On 10/24/24, the night nurse had informed the on-call nurse the resident was not picked up for dialysis.
-He/She did not notify or report to anyone about the resident not being picked up on 10/24/24 since the on-call nurse had already been contacted.
-He/She spoke with Family Member A on 10/24/24, but did not notify him/her the resident had missed dialysis on 10/22/24 and 10/24/24.
During an interview on 10/28/24 at 5:38 P.M., Certified Nursing Aide (CNA) A said:
-On 10/25/24 he/she could tell the resident was not feeling well and asked to be taken back to his/her room.
-On 10/25/24 at 10:30 A.M. he/she found the resident in his/her room on the floor.
-He/She notified the nurse of the resident on the floor, the nurse assessed the resident and he/she assisted getting the resident to bed.
During an interview on 10/28/24 at 2:41 P.M., the Unit Manager said:
-He/She was unsure who called the dialysis center to inform the center the resident was not coming to dialysis on 10/22/24 and 10/24/24.
-The charge nurse was responsible for ensuring the resident went to dialysis.
-He/She observed the resident was in his/her room on 10/26/24, had not had breakfast at that time, and appeared to be sleepy.
-During his/her engagement with the resident on 10/26/24, the resident stood with minimal assist to place a Hoyer pad under him/her with no issues.
-On 10/26/24, he/she observed some swelling around the resident's eyes.
During an interview on 10/28/24 at 4:58 P.M., LPN B said:
-On 10/26/24 he/she was the charge nurse for the resident.
-During report on 10/26/24 at 6:45 A.M., he/she noticed the resident had not left for dialysis.
-He/She was told the resident had not been to dialysis all week.
-He/She reviewed the resident's chart and noted the resident had returned to the facility on [DATE], ordered dialysis three times per week on Tuesday, Thursday and Saturday.
-The resident was to go to dialysis on 10/22/24 and 10/24/24, but transportation was not set up.
-He/She notified the DON of the resident not being picked up for dialysis and was instructed to set up transportation and schedule a new chair time with the dialysis center.
-He/She was able to arrange a new chair time for 10/26/24 at 11:30 A.M. as well as set up transportation.
-The resident was tired after breakfast, but was aware he/she was going to dialysis.
-About 30 minutes after the resident left for dialysis, he/she received a call from the dialysis center to inform the facility the resident was not stable enough for dialysis and was sent to the hospital.
-When he/she noticed the resident had not been to dialysis, he/she felt it was a priority to get the resident to dialysis.
-When he/she spoke to the hospital she was informed the resident had elevated potassium and low hemoglobin which required a blood transfusion before the resident had dialysis.
-The resident had been in the facility for some time and everyone knows his/her dialysis schedule.
-The resident's admission to the hospital was due to missing dialysis.
-The Admissions Director was responsible for setting up all dialysis transportation at admission.
During an interview on 10/28/24 at 2:10 P.M., Dialysis Center Staff A said:
-On 10/22/24 and 10/24/24 the facility called the dialysis center stating transportation did not show up for the resident and they were not sending the resident to dialysis on those days.
-When the facility called the dialysis center on 10/26/24, the facility left a message that the resident was not coming due to no transportation.
-He/She called back to the facility on [DATE] and spoke to LPN B to inform him/her it was not ok for the resident to not come to dialysis.
-He/She advised LPN B on 10/26/24 the resident either needed to come to dialysis or go to the hospital for dialysis treatment.
-He/She took care of the resident on 10/26/24.
-Upon arrival the resident was out of it when he/she was weighing the resident.
-Once the resident was taken back to the dialysis chair, the resident was not responding and his/her face was swollen.
-Due to the resident's change in level of consciousness, his/her tongue hanging out of his/her mouth and drooling, emergency medical services (EMS) was called to take the resident to the hospital.
-He/She assessed the resident and it was determined the resident was too unstable to receive dialysis at the dialysis center.
During an interview on 10/28/24 at 11:38 A.M., the Administrator said:
-He/She was made aware of the resident not making it to dialysis on 10/26/24 by LPN B.
-The new Admissions Director was not aware he/she was supposed to set up transportation for the resident when the resident was readmitted on [DATE].
-The Admissions Director was still learning his/her position and had only been working in the facility for about a week and a half.
During an interview on 10/28/24 at 11:50 A.M., the Director of Nursing (DON) said:
-He/She was notified on 10/26/24 the resident was not picked up for dialysis.
-They tried to locate transportation once he/she was notified.
-They were able to get the resident to dialysis.
-The resident was sent to the hospital from dialysis due to altered mental status.
-The resident missed dialysis on 10/22/24 and 10/24/24.
-He/She was not notified of the resident missing dialysis on 10/22/24 and 10/24/24.
-The resident last had dialysis before leaving the hospital on [DATE].
-Transportation had been canceled when the resident was in the hospital from [DATE] through 10/20/24.
-He/She said the ball was dropped and the transportation was not set up after the resident returned on 10/20/24.
-The facility had an in-house driver for transport, but the staff failed to notify the driver or supervisors the resident was in need of transport services for dialysis.
-The resident had been in the facility for a lengthy amount of time and staff should have known the resident needed to go to dialysis.
During an interview on 10/28/24 at 12:09 P.M., Family Member A said:
-He/She had a meeting at the facility on 10/28/24 related to the resident not being transported to dialysis.
-He/She was not aware of the resident missing dialysis on 10/22/24 and 10/24/24.
-He/She was contacted by another patient at the dialysis center on 10/26/24 asking why the resident was not at dialysis.
-He/She contacted the dialysis center on 10/26/24 and was told the resident did not come to dialysis for the third consecutive scheduled time.
-The last time the resident had a dialysis treatment was prior to being discharged from the hospital on [DATE].
-He/She contacted the facility on 10/26/24 at approximately 8:00 A.M., at which time he/she was told the resident was at the desk and the staff was arranging transport to dialysis.
-The resident arrived at the dialysis center on 10/26/24 at approximately 11:00 A.M.
-He/She was concerned that upon arrival at the dialysis center the resident was unresponsive and was sent to the hospital.
-He/She was told there had been a change in management and the transportation got confused.
-This was the first time anything like this has happened at the facility.
-He/She was upset that no phone calls were made to him/her and he/she was not aware the resident had missed dialysis.
-If he/she had known the resident was in need of transportation to dialysis, he/she would have taken the resident him/herself.
During an interview on 10/28/24 at 12:35 P.M., the Admissions Director said:
-He/She started at the facility on 10/10/24.
-He/She was not aware it was his/her responsibility to set up transportation for new admissions or readmissions until 10/26/24.
-When a resident is admitted /readmitted he/she is supposed to review the admission documentation within a timely manner.
-He/She reviewed admission documents and was aware of the resident's dialysis, but was not aware at that time it was his/her job to set up the transportation for dialysis.
-If he/she would have known it was his/her responsibility to schedule the transportation, he/she would have set it up when the resident readmitted to the facility on [DATE].
- The resident missing dialysis on 10/22/24 and 10/24/24 could have been prevented had he/she been made aware it was his/her responsibility to set up transportation.
-He/She was made aware the resident had missed dialysis on 10/22/24 and 10/24/24 on 10/26/24 when the charge nurse initiated an alert to administrative staff about the resident not having transportation for dialysis.
-He/She was aware there was a driver in-house for transportation needs.
During an interview on 10/28/24 at 1:37 P.M., the Nurse Practitioner said:
-He/She was aware the resident readmitted and did see the resident for readmission on [DATE].
-Was not aware the resident had missed dialysis on 10/22/24 and 10/24/24.
-He/She expected the resident to resume dialysis and staff to communicate with transportation to ensure the residents were getting to dialysis.
-The nurses and nurse managers should have ensured the resident was getting dialysis.
-The resident's hospital admission was a result of not receiving dialysis for six days.
-Missing dialysis had a significant impact on the resident's health status.
-The resident had dementia and would not have known whether or not he/she missed or needed to go to dialysis.
During an interview on 10/28/24 at 2:41 P.M., the Unit Manager said:
-He/She was notified on 10/26/24 prior to getting to the facility about the resident not being picked up for dialysis.
-It was reported to him/her the resident either needed to go to dialysis or to the hospital for dialysis due to missing dialysis on 10/22/24 and 10/24/24 due to no transportation.
-He/She had not been made aware the resident had not been to dialysis since the resident returned to the facility on [DATE].
-On 10/26/24 he/she spoke to Family Member A to discuss the resident not being at dialysis since return and reassured him/her that transportation would be set up for the resident to get to dialysis as ordered.
-Dialysis transportation was usually set up by the admission Director at the time a resident was admitted /readmitted to the facility.
-He/She was not aware of any checks and balances to ensure transport was in place.
-Dialysis appointments were set to populate on the TAR for residents who required dialysis to include the date, time and transportation company.
-He/She expected to be informed of the resident not being transported to dialysis.
-Although the IDT meets daily, he/she did not recall the resident being discussed related to missing dialysis for any reason.
During an interview on 10/28/24 at 3:37 P.M., LPN C said:
-He/She was the on-call nurse from 10/21/24 through 10/27/24.
-On 10/24/24 he/she was notified the resident did not go to dialysis due to no transportation by the charge nurse, he/she advised to give transport a little more time as they could be running late and to pass the information on to LPN A.
-Upon arrival at the facility on 10/24/24 LPN A was aware of the transportation concerns, therefore he/she did not pursue any follow up at that time.
-He/She was not informed of the resident missing dialysis on 10/22/24 until 10/26/24.
-The resident had been at the facility prior to readmission on [DATE] with dialysis transportation in place.
-There had not been prior concerns about the resident not making it to dialysis due to transportation in the past.
-The Admissions Director was responsible for setting up transportation to dialysis upon admission/readmission of the resident on 10/20/24.
-The resident's admission to the hospital could have been prevented if the transportation concern had been resolved or set up at admission.
-The resident has had several hospitalizations related to dialysis.
During an interview on 10/29/24 at 11:51 A.M., the Dialysis Center Staff said:
-The resident's increased potassium level was a direct result of missing dialysis. Missing dialysis resulted in increased toxins in the body and altered mental status.
-He/She had never seen the resident with altered mental status.
-The resident had been very compliant with dialysis and had never missed dialysis consistently in the past.
-The resident had a recent repair of his/her fistula (dialysis access).
-Complications of the fistula could result if not used, causing clotting and/or stenosis (a narrowing of a tubular structure or blood vessel).
-The resident's low hemoglobin was a result of missing dialysis due to not receiving the iron and Mircea (a medication to promote red blood cell production) while at dialysis. The resident did not receive the routine laboratory monitoring and medications while at dialysis.
During an interview on 10/29/24 at 1:11 P.M., the Medical Director said:
-He/She was aware the resident was admitted to the hospital on [DATE].
-He/She was not informed the resident missed dialysis on 10/22/24 and 10/24/24.
-He/She was not aware of the resident's fall on 10/25/24, therefore was not aware of the resident's potential decline due to missing dialysis on 10/22/24 and 10/24/24.
-He/She believed the resident's fall on 10/25/24 and admission to the hospital 10/26/24 was the result of missing dialysis on 10/22/24 and 10/24/24.
-There was no reason for him/her to not be notified as he/she is at the facility every Tuesday and Thursday.
-He/She did not understand why the staff did not ensure the resident was transported to dialysis.
During an interview on 10/29/24 at 3:10 P.M., the Administrator said:
-He/She was not made aware of the resident missing dialysis on 10/22/24 or 10/24/24.
-He/She was not aware of the potential change in condition on 10/25/24.
-He/She was not aware there were concerns related to transportation to dialysis until 10/26/24 when LPN B initiated the alert to department heads.
-The resident fall and hospitalization was preventable and the staff should have alerted him/her, the Medical Director, the DON, the Unit Manager, Social Services, in-house transportation, the Admissions Director and/or the family.
During an interview on 10/31/24 at 11:29 A.M., LPN A said:
-He/She were responsible for the resident on 10/22/24 and 10/24/24.
-The relevance of dialysis was life or death.
-If he/she had notified someone of transportation concerns, the resident may not have missed dialysis which resulted in the resident's admission to the hospital on [DATE].
During an interview on 10/31/24 at 12:26 P.M., the Social Services Designee said he/she would have been notified of the resident needing transportation to dialysis, he/she would have assisted with arranging transport.
During an interview on 10/31/24 at 12:49 P.M., the DON said if the staff had notified the physician, family, DON or any other department head in real time the resident would not have missed dialysis which resulted in the resident's admission to the hospital.
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
MO00244188
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff notified the next of kin, physician, and depar...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff notified the next of kin, physician, and department heads when one sampled resident (Resident #1) missed dialysis on 10/22/24 and 10/24/24, had increased blood pressure, and had a fall on 10/25/24. The resident was hospitalized on [DATE]. The facility census was 91 residents.
Review of the facility Coordination of Care Policy, dated 5/20/24, showed:
-The purpose of the policy was to establish a framework for effective coordination of care for the residents in the facility.
-The policy aims to enhance communication among interdisciplinary team members, ensure continuity of care, and improve health outcomes for residents.
-Care coordination will be facilitated through effective communication, shared decision-making, and the involvement of residents and their families in the care planning process.
-Regular interdisciplinary (IDT) team meetings will be held at least weekly to discuss resident care plans, progress, and any necessary adjustments to treatment.
-All team members must document relevant communication in the resident's medical record to ensure continuity of care and shared understanding.
-A designated staff member will be responsible for communicating any significant changes in a resident's condition to all relevant team members promptly.
1. Review of Resident #1's admission Record showed the resident readmitted on [DATE] with diagnoses including End-Stage Renal Disease (ESRD), dependence on renal dialysis, and hemiplegia and hemiparesis (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain), following cerebral infarction (stroke) affecting right dominant side.
Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 8/1/24, showed the resident severely cognitively impaired.
Review of the resident's undated Care Plan showed:
-The resident had a diagnosis of ESRD and was on dialysis Tuesday, Thursday and Saturday at the dialysis center, chair time from 6:30 A.M. to 10:00 A.M.
--Monitor hemodialysis access site for signs and symptoms of complications and report abnormal findings to physician and/or dialysis center.
-Dialysis: Resident required hemodialysis related to end stage renal failure and was at risk for deficient/excess fluid volume, edema, high blood pressure and infection.
-Falls: Resident at risk for fall with or without injury related to altered balance while standing and/or walking, altered mental status, antihypertensive medication, diuretic medication, history of falls, seizure disorder, and unsteady gait.
--Monitor for changes in condition affecting risk for falls and notify physician if observed.
-Resident had an unwitnessed fall and is at risk for recurring falls, 6/17/24.
--Monitor for complications related to the fall and notify physician promptly if observed.
Review of the resident's Order Summary Report for October 2024 showed:
-Dialysis: Complete observation tab, print and send with patient to dialysis, also collect once patient returns and place in the medical records bin to be scanned to the patient chart, one time a day every Tuesday, Thursday and Saturday for dialysis, ordered 4/26/24.
-Dialysis center days and times of treatment, Tuesday, Thursday, and Saturday and name of transportation, ordered 4/30/24.
-Dialysis pre-weight one time a day every Tuesday, Thursday, and Saturday, ordered 4/26/24.
-Dialysis post weight one time a day every Tuesday, Thursday, and Saturday, ordered 4/26/24.
Review of the resident's Treatment Administration Record (TAR) for 10/1/24 through 10/31/24 showed:
-Dialysis: Complete observation tab, print and send with patient to dialysis, also collect once patient returns and place in the medical records bin to be scanned to the patient chart, one time a day every Tuesday, Thursday and Saturday for dialysis- not documented as completed on 10/22/24.
-Dialysis center days and times of treatment, Tuesday, Thursday, and Saturday and name of transportation, resident was to be picked up at 5:45 A.M. by a third party transportation company on dialysis days.
-Dialysis pre-weight one time a day every Tuesday, Thursday and Saturday- not documented as completed on 10/22/24.
-Dialysis post weight one time a day every Tuesday, Thursday and Saturday- documented as other, see nurse's notes on 10/22/24 and 10/24/24.
Review of the resident's Nurse's Note, dated 10/22/24 at 2:04 P.M., showed dialysis post weight one time a day every Tuesday, Thursday, and Saturday for weight, no additional notes were signed by Licensed Practical Nurse (LPN) A.
Review of the resident's Nurse's Note, dated 10/24/24 at 8:15 P.M., showed dialysis post weight one time a day every Tuesday, Thursday and Saturday for weight- patient did not go to dialysis, signed by LPN A. No further nurse's notes for 10/25/24.
Review of the resident's medical record showed no documentation the physician, family, or department heads were notified of the missed dialysis on 10/22/24 or 10/24/24 until 10/26/24
Review of the resident's un-witnessed fall report, dated 10/25/24 at 9:30 A.M., showed:
-The nurse alerted by Certified Nurse Aide (CNA) A that the resident had fallen.
-The resident was laying on his/her right side in a fetal position.
-No injuries noted.
-Predisposing factors, recent change in cognition.
-Notifications: Director of Nursing (DON), Family Member A, and Medical Director on 10/25/24 at 10:10 A.M.
Review of the resident's Rehab-Status Post-Fall Screen, dated 10/25/24 at 10:16 A.M., showed:
-The resident had a non-injury fall in room.
-No injury noted.
-Information reported to IDT at Stand-up Meeting by: no therapist noted, no notes for reporting.
Review of the resident's Neurological Assessment Flow Sheet, dated 10/26/24, showed facility staff documented the resident's blood pressure (B/P) was as high as 211/92 (normal 120/80), pupil assessment was normal and hand grasps were greater on the left than the right. The resident was transferred to the hospital from dialysis on 10/26/24 signed by the Unit Manager.
Review of the resident's medical record showed staff did not notify the physician of the resident's blood pressure of 211/92 on 10/26/24, prior to being sent to dialysis.
Review of the resident's Nurse's Note, dated 10/26/24 at 10:50 A.M., showed the resident left for dialysis at this time transported by a third-party transport company, signed by LPN A.
Review of the resident's Nurse's Note, dated 10/26/24 at 7:09 P.M., showed:
-Resident admitted to the hospital for elevated potassium and low hemoglobin.
-Resident transferred from dialysis this morning to the hospital.
During an interview on 10/28/24 at 11:50 A.M., the DON said:
-The resident missed dialysis on 10/22/24 and 10/24/24.
-He/She was not notified of the resident missing dialysis on 10/22/24 and 10/24/24.
-The facility had an in-house driver for transport, but the staff failed to notify the driver or supervisors the resident was in need of transport services for dialysis.
-The resident had been in the facility for a lengthy amount of time and staff should have known the resident needed to go to dialysis.
During an interview on 10/28/24 at 12:09 P.M., Family Member A said he/she had not been notified of the resident's missed dialysis or the resident's fall.
During an interview on 10/28/24 at 1:37 P.M., the Nurse Practitioner said:
-He/she was not aware the resident had missed dialysis on 10/22/24 and 10/24/24.
-He/she was not notified of the resident fall.
-He/she would of expected notification of the fall.
During an interview on 10/28/24 at 2:10 P.M., Dialysis Center Staff A said:
-On 10/22/24 and 10/24/24, the facility called the dialysis center stating transportation did not show up for the resident and they were not sending the resident to dialysis on those days.
-When the facility called the dialysis center on 10/26/24, the facility left a message that the resident was not coming due to no transportation.
-He/She called back to the facility on [DATE] and spoke to LPN B to inform him/her it was not ok for the resident to not come to dialysis.
-He/She advised LPN B on 10/26/24 the resident either needed to come to dialysis or go to the hospital for dialysis treatment.
-He/She took care of the resident on 10/26/24.
-Upon arrival the resident was out of it when he/she was weighing the resident.
-Once the resident was taken back to the dialysis chair, the resident was not responding and his/her face was swollen.
-Due to the resident's change in level of consciousness, his/her tongue hanging out of his/her mouth and drooling, emergency medical services (EMS) was called to take the resident to the hospital.
-He/She assessed the resident and felt the resident was too unstable to receive dialysis at the dialysis center.
During an interview on 10/28/24 at 2:41 P.M., the Unit Manager said:
-It was reported to him/her the resident either needed to go to dialysis or to the hospital for dialysis due to missing dialysis on 10/22/24 and 10/24/24 due to no transportation.
-He/She had not been made aware the resident had not been to dialysis since the resident returned to the facility on [DATE].
-He/She expected to be informed of the resident not being transported to dialysis.
-Although the IDT meets daily, he/she did not recall the resident being discussed related to missing dialysis for any reason.
-He/she was not notified of the resident fall.
During an interview on 10/28/24 at 3:37 P.M., LPN C said:
-He/She was the on-call nurse from 10/21/24 through 10/27/24.
-On 10/24/24 he/she was notified the resident did not go to dialysis due to no transportation by the charge nurse, he/she advised to give transport a little more time as they could be running late and to pass the information on to LPN A;
-Upon arrival at the facility on 10/24/24 LPN A was aware of the transportation concerns, therefore he/she did not pursue any follow up a that time.
-He/She was not informed of the resident missing dialysis on 10/22/24 until 10/26/24.
During an interview on 10/29/24 at 1:11 P.M., the Medical Director said:
-He/She was aware the resident was admitted to the hospital on [DATE].
-He/She was not informed the resident missed dialysis on 10/22/24 and 10/24/24.
-He/She was not aware of the resident's fall on 10/25/24, therefore was not aware of the resident's potential decline due to missing dialysis on 10/22/24 and 10/24/24.
-There was no reason for him/her to not be notified as he/she is at the facility every Tuesday and Thursday.
During an interview on 10/29/24 at 2:06 P.M., the DON said:
-He/She was not notified of the resident's fall until 10/28/24 during morning meeting.
-He/She was not sure if anyone else had been notified, such as the physician and the family.
-He/She expected to be notified immediately to begin an investigation.
During an interview on 10/29/24 at 3:10 P.M., the Administrator said:
-He/She was not made aware of the resident missing dialysis on 10/22/24 or 10/24/24.
-He/She was not aware of the resident's fall or potential change in condition on 10/25/24.
-He/She was not aware there were concerns related to transportation to dialysis until 10/26/24 when LPN B initiated the alert to department heads.
-He/She feels this was preventable and the staff should have alerted him/her, the Medical Director, the DON, the Unit Manager, Social Services, in-house transportation, the Admissions Director, and the family.
During an interview on 10/31/24 at 10:16 A.M., LPN D said the expectation is to notify the family, physician, and administrative staff any time there was a change with a resident such as a fall or missed appointment.
During an interview on 10/31/24 at 11:29 A.M., LPN A said:
-He/She was the nurse for 10/22/24 and 10/24/24.
-The relevance of dialysis was life or death.
-If he/she had notified someone of transportation concerns, the resident may not have missed dialysis which resulted in the resident's admission to the hospital on [DATE].
During an interview on 10/31/24 at 12:13 P.M., the Unit Manager said:
-He/She expected staff to notify the physician, family, unit manager, DON and any other relevant parties in a timely manner about any changes such as a fall, missing dialysis or any other changes pertaining to a resident.
-He/She expected LPN A to make the necessary notifications about the resident not being picked up for dialysis on 10/22/24 and 10/24/24 by 7:30 A.M. on those dates.
-He/She felt there was no reason for LPN A to not make the notifications on 10/22/24 and 10/24/24 as there were no emergencies and there was a provider in the building Monday through Friday.
During an interview on 10/31/24 at 12:26 P.M., the Social Services Designee said if he/she would have been notified of the resident needing transportation to dialysis, he/she would have assisted with arranging transport.
During an interview on 10/31/24 at 12:49 P.M., the DON said if the staff had notified the physician, family, DON or any other department head in real time the resident would not have missed dialysis which resulted in the resident's admission to the hospital.
MO00244188
May 2024
13 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a major mental illness diagnosis had a requi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a major mental illness diagnosis had a required DA-124C/Level I Preadmission Screening and Resident Review (PASARR - used to evaluate the presence of psychiatric conditions to determine if a PASARR Level II screen is required) in a timely manner for care planning purposes for one sampled resident (Resident #65) out of 21 sampled residents. The facility census was 105 residents.
Review of the facility's PASARR policy, revised 11/2016 showed:
-The DA-124C (PASARR Level I) must be completed on all potential residents prior to admission to screen individuals for mental illness (MI) and intellectual/developmental disability (ID/DD) or related conditions regardless of the resident's method of payment or known diagnoses. It must be determined if the individual requires the level of services provided by the facility or if they need specialized treatment for MI or ID/DD diagnosis.
-For residents appropriate for a PASARR Level II review, the facility will incorporate the recommendations from the PASARR Level II determination and evaluation report into the resident's assessment, care planning, and transitions of care.
-The facility shall refer any resident for Level II review upon significant change in status or condition such as a possible mental disorder or intellectual disability or related condition.
-A copy of the completed screening is to be placed in the resident's medical record.
1. Review of Resident #65's admission Record showed he/she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with a diagnosis of:
-Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event. Symptoms may include flashbacks, nightmares, and severe anxiety).
-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Adjustment disorder with anxiety (strong emotional or behavioral reaction to stress or trauma).
-Insomnia (difficulty falling or staying asleep or getting good quality sleep).
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 2/5/24 showed the resident was moderately cognitively impaired and was diagnosed with PTSD.
Review of the resident's Psychiatric Conditions care plan, initiated 2/8/24 showed the resident had a history of:
-PTSD.
-Depression.
-Adjustment disorder with anxiety.
-Insomnia.
Review of the resident's PASARR Level I, dated 5/1/24 showed:
-The resident had a diagnosis of PTSD.
-Other mental disorders included depression, adjustment disorder with anxiety, and insomnia.
During an interview on 5/6/24 at 11:48 A.M. Social Worker A said:
-He/She was responsible for ensuring the DA-124C was completed immediately upon the resident's admission if they do not already have one.
-The resident was private pay status. He/She knew the PASARR Level I was required for Medicaid residents, but did not realize they were required for private pay residents as well until 5/1/24.
-He/She submitted the resident's DA-124C on 5/1/24 when he/she learned it was required of all residents, regardless of method of payment.
During an interview on 5/6/24 at 12:44 P.M. the Director of Nursing (DON) said:
-The facility social workers were responsible for ensuring the DA-124C was completed prior to or upon admission.
-The Level I PASARR was required of all residents regardless of how they pay.
-Any resident expected to stay past 30 days should have a Level I PASARR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 an ongoing activity program based on a compreh...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing activity program based on a comprehensive assessment and care plan of each resident's interests, hobbies, and abilities for two sampled residents (Residents #7 and #44) out of 21 sampled residents. The facility census was 105 residents.
When a policy for Activities was requested, the facility provided a training manual titled Missouri Health Care Association Activity Director Training Binder dated 3/8/17. There was no facility policy specific to activities included in the manual. The manual did include the State Operations Manual (SOM) Activity Regulation and guidance for this regulation.
1. Review of Resident #7's undated admission record that was printed on 5/2/24 showed:
-The resident was receiving hospice care (end of life care).
-Some of the resident's diagnoses included psychosis (a mental disorder characterized by a disconnection from reality), anxiety disorder (psychiatric disorder that involve extreme fear, worry, and nervousness), dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes), bipolar disorder (a disorder characterized by extreme mood swings from depression to mania), and depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life).
Review of the resident's Observation Detail List Report dated 11/21/23 showed:
-The resident was living in Assisted Living but had declined and moved to this facility.
-The resident liked reading his/her Bible, church services, bingo, live music, pet visits, music from the 40's and 50's, family visits, and crafts.
-The resident had always been very social.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/23/23 showed the following staff assessment of the resident:
-The resident was severely cognitively impaired.
-Music, pets, and religious activities were very important to him/her.
-Reading, keeping up with the news, doing his/her favorite activities, going outside, and doing activities with groups of people were somewhat important to him/her.
Review of the resident's recreation/wellness care plan dated 1/5/24 showed:
-Activities were important to the resident.
-The goal was for the resident to participate in one group activity of preference weekly.
-Instructions to assist the resident to and from activities of choice such as exercise, live music, and television.
-Instructions to help the resident manage behavior as to not be disruptive such as talking out loudly during events.
-Instructions to encourage conversation/socialization with others who have similar interest Bible Study, devotions, live music, and crafts.
-Instructions to provide the resident with verbal reminders to scheduled activities of his/her preference which included live music, exercise, and pet visits.
-Instructions to put a calendar/schedule of events in his/her room where he/she could clearly see it.
Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:
-No hearing impairment.
-No vision impairment with corrective lenses.
-Clear speech.
-Understands others and was understood by others.
-Displayed indicators of mild depression.
-Did not have any behaviors.
-Dependent on staff for all cares except only needed supervision while eating.
-Some of his/her diagnoses included heart disease, dementia, anxiety, depression, and bipolar disease.
-Was on hospice care.
Review of the Activity Progress Note dated 2/19/24 showed:
-The resident spent most of his/her time sitting in the unit's living room.
-The resident paid some attention to the television during movies and throwback television shows.
-The resident called out from his/her room for attention as he/she forgets to push the button.
-The resident participated in exercise class the past quarter.
Review of the resident's activity participation records dated February 2024 showed the resident participated in trivia once and left early.
Review of the resident's activity participation records dated March 2024 showed the resident participated in bingo twice, pet visits four times, live entertainment once, and Bible study once.
Review of the resident's activity participation records dated April 2024 showed the resident participated in beverage cart once and church service once.
Observation on 4/29/24 showed:
-At 9:51 A.M.:
--The resident was in his/her room in his/her broda chair (a wheelchair specialized for the resident's comfort that usually reclines and is padded).
--The resident said he/she needed staff assistance.
--Staff responded to the resident's call light.
-At 1:51 P.M., staff entered the resident's room with a mechanical lift and closed the resident's door.
-At 2:36 P.M.:
--The resident was in his/her room with the television on.
--The resident said he/she was not sure how he/she was doing.
--The resident said the television was on all day Saturday, Sunday and today (Monday).
--The resident said he/she liked television in general, but he/she didn't like television that much.
--The resident talked about his/her cats when he/she looked at a picture of them that was in his/her room.
Observation on 4/30/24 showed:
-At 9:13 A.M., the resident was not in his/her room.
-At 10:23 A.M., the resident was in his/her room and a cooking show was on the television.
-At 3:21 P.M.:
-The resident was in bed and the television was on a reality show about a restaurant and bar owner and the staff that worked at the restaurants and bars.
-The resident said he/she was watching something about families, but he/she didn't have a remote control to change the channel.
-The resident said he/she told the maintenance assistant about his/her missing remote control.
Observation on 5/1/24 showed:
-At 9:20 A.M. and 9:56 A.M., the resident was in his/her broda between the nurses' station and the back of the couch that faced the television.
-At 10:19 A.M., the resident was in his/her room in his/her broda chair with the television on.
-At 10:28 A.M.,
--The resident was in his/her room in his/her broda chair with the television on.
--The television was on a reality show about affluent housewives.
--The resident read the name of the television show from the television screen.
--When asked if he/she liked the television show, he/she said, Well, it's what was on.
-At 1:26 P.M., the resident was not in his/her room.
-At 2:48 P.M.:
--The resident was in his/her room in his/her broda chair.
--The resident was calling out the charge nurse's name repeatedly.
--The television was on a reality show about a competition between chefs.
--The resident said all that's been on his/her television for two days were reality shows and she didn't have the remote control.
Observation on 5/2/24 showed:
-At 5:06 A.M., the resident was asleep in bed and the television was on loud on a reality show.
-At 5:29 A.M., the resident's door was closed.
-At 10:02 A.M., the resident's door was closed, and voices could be heard in the resident's room.
Observation on 5/3/24 showed:
-At 10:06 A.M. and 10:33 A.M., the resident was sitting in the living room area by the television but not looking at the television.
-At 1:40 P.M., the resident was asleep in bed.
-At 3:16 P.M., the resident was in bed, was yelling for help, and calling out his/her room number. Staff entered the room and asked if the resident was ready to get out of bed.
During an interview on 5/3/24 at 10:16 A.M., Certified Nursing Assistant (CNA) A said the resident got along with two other residents that watched television together in the television area of the living room.
Observation on 5/6/24 at 9:15 A.M. showed the resident was in his/her room in his/her broda chair and the television was on a talk show where people are arguing and yelling at each other.
During an interview on 5/6/24 at 10:37 A.M., Activities Director said:
-The resident had hysteria (exaggeratedly or inappropriately emotional behavior).
-When the resident attended activities, he/she was disruptive.
-The resident did participate successfully in exercise recently.
-The resident had less calling out recently.
-The resident liked pet visits and live entertainment.
During an interview on 5/6/24 at 11:28 A.M., the Activities Director said:
-The resident was much more apt to converse recently, with less calling out.
-The resident did great with exercise recently.
2. Review of Resident #44's undated admission record that was printed on 5/2/24 showed:
-The resident was receiving hospice care.
-Some of the resident's diagnoses included delusional disorder (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder, dementia, bipolar disorder, and depression.
Review of the resident's annual MDS dated [DATE] showed the following staff assessment of the resident:
-Had minimal hearing impairment, clear speech, usually understood others and others usually understood him/her.
-Was severely cognitively impaired.
-Displayed indicators of mild depression.
-Had no behaviors.
-Reading, music, pets, doing his/her favorite activities, and being outside were somewhat important to the resident.
-The resident used a wheelchair.
-The resident was dependent upon staff for most cares except eating required set-up only.
-Some of his/her diagnoses included a stroke, dementia, anxiety disorder, depression, and bipolar disorder.
-Was receiving hospice care.
Review of the resident's Recreation/Wellness assessment dated [DATE] showed:
-The resident did not use the phone.
-Preferred to be at the nurses' station or sitting in his/her doorway visiting with staff and others or resting in bed.
-Reading, music, pets, going outside, and doing his/her favorite activities were somewhat important to him/her.
-The resident flipped through a magazine occasionally at the nurses' station but was no longer a reader.
-The resident liked live music.
-The resident's favorite activities included resting, visits with family and staff and having snacks.
Review of the resident's Recreation/Wellness progress note dated 2/7/24 showed:
-The resident was content to rest, watch some television and sit in the living room for movies.
-The resident visited with care staff, enjoyed snacks, and pet visits.
-The resident liked cola from the beverage cart and ice cream.
-The resident would be taken outside when the weather is warmer.
Review of the resident's Recreation/Wellness care plan updated 2/7/24 showed:
-The goal was that the resident would have positive responses to activities of his/her choice such as talking to family on the phone, pet visits, snacking on bananas, large print books or magazines about gardening.
-Interventions included:
--Check with the resident weekly to determine my satisfaction of leisure activities.
--Encourage conversation/socialization with others who have similar interests in family, gardening, Methodist church, and sewing.
--Provide modification/adaptations such as large print books or magazines.
--Put a calendar/schedule of events in my room where I can clearly see it.
--Consider a small version of the calendar for his/her table tray for easier access and sight.
Review of the resident's activity participation records dated February 2024 showed the resident participated in guitar music once.
Review of the resident's activity participation records dated March 2024 showed the resident participated in bingo once, church once, Bible study once, a movie once, exercise once, and pet visits four times.
Review of the resident's activity participation records dated April 2024 showed the resident participated in the beverage cart once and church once.
Observation on 4/29/24 showed:
-At 10:07 A.M., the resident was sitting in his/her wheelchair in his/her room and was not engaged in any activity.
-At 2:48 P.M., the resident was asleep in bed.
Observation on 4/30/24 showed:
-At 9:14 A.M., the resident was not in his/her room.
-At 10:24 A.M., the resident's door was closed.
-At 3:23 P.M., the resident was asleep in bed.
Observation on 5/1/24 showed:
-At 9:20 A.M., the resident was in his/her wheelchair in the living room area between the nurses' station and couch that faced the television, not engaged in any activity.
-At 9:56 A.M., the resident was in his/her wheelchair in the living room area between the nurses' station and couch that faced the television, not engaged in any activity.
-At 10:15 A.M., the resident was in his/her wheelchair in the living room area between the nurses' station and couch that faced the television, not engaged in any activity.
-At 10:17 A.M., CNA A told the charge nurse the resident asked to be laid down.
-At 1:25 P.M., the resident was asleep in bed.
-At 2:54 P.M., the resident was asleep in bed.
Observation on 5/2/24 showed:
-At 5:07 A.M., the resident was in his/her wheelchair in the living room area across from the nurses' station, not engaged in any activity.
-Continuous observation from 5:15 A.M. to 6:40 A.M. showed:
-At 5:15 A.M.:
--The resident was in his/her wheelchair in the living room area across from the nurses' station with his/her head down and eyes closed.
--The resident opened his/her eyes, and looked toward the television, which was about 12 feet away.
-At 5:16 A.M.:
--The resident was looking towards the piano to his/her right.
--Staff turned the television on to the news.
-At 6:40 A.M., a staff member took the resident to his/her room and came back out and placed the resident in the living room area.
-At 10:03 A.M., the resident was in his/her wheelchair in the living room area by the bird aviary with his/her head down, not engaged in any activity.
Observation on 5/3/24 showed:
-At 10:07 A.M.,
--The resident was by the bird aviary with his/her wheelchair sideways to the bird aviary.
--The resident said he/she watched the birds every day.
-At 10:33 A.M., the resident was sitting by the nurses' station, not engaged in any activity.
During an interview on 5/3/24 at 10:16 A.M., CNA A said the resident:
-Had good days and bad days.
-Liked to lie down in the afternoon.
-Would talk to anyone passing by.
-Liked it when the staff were goofy.
-Would not play bingo.
-Would listen to music entertainers.
Observation on 5/6/24 at 9:16 A.M. showed the resident was sitting in his/her wheelchair behind a lazy boy chair in the living room area, not engaged in any activity.
During an interview on 5/6/24 at 10:37 A.M., the Activity Director said the resident liked pet visits, snack cart, cola, movies, throwback television.
During an interview on 5/6/24 at 11:28 A.M., the Activity Director said:
-The resident stayed by the nurses' station and visited with staff there.
-The resident often sat in the living room and watched television or movies.
-The resident liked pet visits and live music/entertainment.
3. During an interview on 5/6/24 at 10:37 A.M., Activities Director said:
-They used a program from 3/1/24 to 4/9/24 to record attendance but they could no longer get into those records.
-The participation sheets he/she provided were the participation sheets for each individual activity.
-The participation sheets were a resident roster with all the residents in the facility with a mark next to the residents that participated in that specific activity.
-They began using a new electronic health records system on 4/10/24.
During an interview on 5/6/24 at 12:08 P.M., the Activities Director said:
-They could do more for all the residents when there were three staff in the Recreation/Wellness department.
-They have a core group of about 20 residents that go to the group activities.
-They could do more with the residents like these residents with different capacities when they had the third person in the department.
-They have thematic memory sets and things for the residents to twiddle with.
-It's a time issue.
-He/She has supplies needed but not the time to do everything needed for all the residents.
During an interview on 5/6/24 at 1:20 P.M., the Administrator said:
-He/she thought the Activity Director provided activities for dependent residents like these two residents.
-There is a second staff member in the Recreation/Wellness department who works in the Assisted Living Facility but also helps at this facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate fall prevention interventions were ad...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate fall prevention interventions were added to a care plan in a timely manner and implemented for one sampled resident (Resident #6)with a history of falls. The facility failed to ensure staff utilized a gait belt (a safety device placed around the waist of residents requiring assistance with transfers and walking) for one sampled resident (Resident #226) who required assistance with transfers out of 21 total sampled residents. The facility census was 105 residents.
Review of the facility's Investigating and Reporting Accidents and Incidents policy, revised July, 2017 showed:
-The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of an accident/incident and shall complete a Report of Incident/Accident form.
-The Director of Nursing (DON) shall ensure the Administrator receives a copy of the Report of Incident/Accident form.
-Incident/Accident reports will be reviewed by the safety committee for trends or safety hazards and to analyze individual resident vulnerabilities.
Review of the facility's Falls Risk Assessment policy, dated March, 2018 showed staff and the attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize consequences of risk factors.
1. Review of Resident #6's admission Record showed the resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with the following diagnoses:
-Multiple Sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability), onset date 1/15/24.
-Muscle weakness, onset date 1/16/24.
-Fracture of right lower leg, subsequent encounter for closed fracture with routine healing, onset date 2/18/24.
-History of falling, onset date 4/18/24.
Review of the resident's Risk for Falls care plan, initiated 1/17/24 showed:
-The resident was at risk for falls related to his/her need for Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) assistance.
-Staff were to:
--Encourage resident to assume a standing position slowly.
--Give verbal reminders not to transfer and ambulate without assistance.
--Keep call light within reach.
--Keep frequently used personal items within reach.
--Provide a clutter-free environment.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 1/22/24 showed the resident:
-Had impaired vision.
-Was severely cognitively impaired.
-Used a walker and a wheelchair.
-Was dependent on staff for toileting, showers, wheeling his/her wheelchair, dressing, and transfers.
-He/She had no falls in the last two to six months prior to admission.
-Had no fractures in the six months prior to admission.
-Had no falls since his/her re-admission.
Review of the resident's Fall Incident Report, dated 2/17/24 showed:
-The resident was found on the floor in his/her room.
-The resident had bare feet and could have been moving about in bed.
-The resident did not complain of pain and was alert; extremity movement and hand grasps were at baseline; pupil size and response were within normal limits; there was no change from the resident's baseline; and no injury was noted at the time.
-There were no known contributing factors to the fall other than the resident could have been moving about in bed.
-An immediate intervention was put into place to lower the resident's bed and to evaluate the resident's toileting schedule needs.
-The fall was unwitnessed and 72-hour post fall follow up (neurological checks and assessments for injuries) started on 2/17/24 and were expected to end on 2/20/24.
-The physician and resident representative were notified and the care plan was reviewed by the nurse by 2:49 A.M.
Review of the resident's nursing note, dated 2/17/24 at 7:15 P.M. showed:
-A family member reported concerns with the resident's knee and said the resident had increased pain.
-A Certified Nursing Assistant (CNA) reported when wheeling the resident to a meal the resident put his/her feet down, stopping the wheelchair. The resident had grimaced in pain. The CNA reported no changes with resident transfers, but the resident always complained of knee pain when moving.
-The nurse looked at the resident's knee with no findings and a Lidocaine Patch (a local pain anesthetic) was placed on the resident's knee.
-The family member asked about the resident's fall and the resident's roommate (no longer at the facility) said he/she heard a big bump at 2:00 A.M. and asked the resident if he/she fell. The resident told the roommate yes and the roommate pushed the call light and called the facility phone for staff assistance.
Review of the facility's Post Fall Investigation Report, dated 2/18/24 showed:
-The resident fell on 2/17/24 at 2:00 A.M.
-The resident:
--Had no history of falls.
--Was identified as being at risk for falls on his/her care plan.
--Was found on the floor and was unable to describe the fall.
-The bed was in the low position and there were no known injuries.
-Neurological assessments (checking the resident's level of consciousness, pupil response, motor functions, hand grasps, movement of extremities, pain response, and vital signs) were started and monitoring was to continue for 72 hours post fall.
-Planned systemic interventions/changes would be frequent rounds and low bed. Family at bedside as able.
-On 2/18/24 radiology took x-ray images of the resident's right hip, knee, and ankle.
Review of the resident's Fall Risk Care Plan, dated 4/5/24 showed:
-The following interventions, all dated 4/5/24:
--Anticipate and meet resident needs.
--Remind resident to call for assistance with transfers.
--Encourage participation in activities that promote exercise and physical activity for strengthening and improved mobility.
--Keep call light and frequently used personal items within reach.
-There was no mention of a lowered bed or frequent rounds for toileting needs.
Review of the resident's nursing note, dated 4/9/24 at 10:50 P.M. showed:
-At approximately 6:45 P.M. the resident was observed lying on the floor by roommate's family.
-The day nurse reported resident was lying face down on the floor next to his/her bed on the side closest to the bathroom.
-Range of motion to upper and lower extremities without complaints of pain.
-Resident noted to have hematoma ( A pool of mostly clotted blood that forms in an organ, tissue, or body space) to his/her right forehead.
-Neurological assessments initiated.
-Resident alert and able to answer simple questions. At baseline cognitively.
-Resident complained of pain, but would not say where pain was.
-Resident assisted back into bed with assistance of two.
-Medical doctor and nurse manager notified.
-Order obtained to send to ER for evaluation.
Review of the resident's Post Fall Investigation Report, dated 4/10/24 showed:
-The resident had an unwitnessed fall in his/her room on 4/9/24 at 7:00 P.M.
-The resident was found on the floor.
-His/Her bed was in the low position.
-Non-compliant resident was indicated as the contributing factor to the fall.
-The resident was sent to the ER for assessment of hi/sher right knee swelling and was found to be febrile upon arrival.
--No documentation of his/her right forehead hematoma.
-Resident family members were notified.
Review of the resident's hospital Discharge Summary, for the 4/9/24 hospitalization showed:
-The resident was admitted to the hospital related to an unwitnessed fall.
-A family member reported the resident was dealing with a right knee effusion (fluid accumulation) for a few months.
-Arthrocentesis (a procedure in which a needle is used to take fluid out of a joint for diagnostic purposes) performed and showed inflammatory effusion. No evidence of infection. Started back on gout (a form of arthritis causing pain, swelling and redness in joints) medication.
-CT of head with no acute intracranial hemorrhage (bleeding). Right frontal scalp swelling. No displaced skull fractures.
-Found to have a multidrug resistant (bacteria that have become resistant to certain antibiotics) bacteria in urine.
-Treatment for Urinary Tract Infection (UTI).
Review of the resident's Fall Risk Care Plan showed the following interventions were added on 4/28/24:
-Keep the bed in the low position with brakes locked.
-Monitor for changes in condition affecting risk for falls and notify physician if observed.
-Safety devices as ordered.
Observation on 4/29/24 and 5/1/24 showed:
-On 4/29/24 at 2:22 P.M. the resident was in the common area near the television. He/She had light bruising and mild swelling to the outside of his/her left eye. He/She was wearing a knee length hard boot on the right lower leg. The resident said he/she did not remember falling.
-On 5/1/24 at 10:25 A.M. the resident was in bed and appeared to be sleeping. His/Her bed was lowered. A fall mat was under, not beside, his/her bed.
During an interview on 5/2/24 at 7:12 A.M. Family Member A said:
-The resident fell out of bed in February and broke his/her right leg.
-The resident fell again in April and got a lump on his/her head and continued to have a bruised and swollen left eye for weeks following the fall.
During an interview on 5/3/24 at 2:40 P.M. CNA C said:
-He/She thought the resident had an intervention for a lowered bed prior to his/her first fall in February.
-After the February fall he/she thought they added the fall mat which was supposed to be beside his/her bed when occupied in case the resident fell.
During an interview on 5/6/24 at 11:38 A.M. Licensed Practical Nurse (LPN) C said:
-He/She thought the resident had an intervention for a lowered bed after his/her fall in February. It should be on the resident's care plan.
-He/She didn't know when a fall mat intervention was added.
During an intervention on 5/6/24 at 11:39 A.M. the 300 Hall Unit Manager said:
-He/She didn't recall what intervention had been added after the February fall.
-After the resident's fall in April the fall mat was added to the resident's care plan.
During an interview on 5/6/24 at 12:06 P.M. MDS Coordinator A said:
-After the resident fell in February he/she had instructions not to bear weight.
-He/She couldn't see in the resident's record that an intervention to lower the resident's bed or any other intervention had been added to the care plan at the time of the fall.
-Typically the team discussed resident falls the next morning in the clinical meeting and new interventions were developed and added then.
During an interview on 5/6/24 at 2:12 P.M. the Director of Nursing (DON) said:
-The Unit Manager (UM) was responsible for the resident's fall investigation and should have added the lowered bed intervention into the resident's fall risk care plan.
-It should have been added after the resident returned from the ER visit in February.
2. Record review of Resident #226's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:
-Fracture of superior rim of right pubis (hip/pelvic area), subsequent encounter, with routine healing.
-History of falling.
Review of the resident's admission MDS, dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Required maximal assistance with transfers including chair to bed, bed to chair, and chair to chair.
-Had no falls in the last two to six months and no fractures related to falls in the six months prior to admission.
-He/She had no falls since admission.
Review of the resident's Baseline Care Plan, dated 4/26/24 showed the resident:
-Had a history of falls prior to admission.
-The resident required maximal assistance with all transfers.
Observation on 5/2/24 at 6:26 A.M. showed:
-CNA F walked into the resident's room announcing he/she was getting the resident up.
-A gait belt was hanging on the wall just inside the door to the right. CNA F did not grab it or any other gait belt.
-The resident was lying on his/her back in bed.
-CNA F told the resident he/she was getting him/her up and put his/her left arm under the resident's left underarm and assisted the resident in sitting up on the side of the bed.
-CNA F placed the resident's wheelchair near to and facing the bed and locked it.
-The resident said he/she felt sick to his/her stomach.
-CNA F put his/her hands under the resident's underarms and asked the resident to stand.
-After the resident stood up CNA F grabbed the back of the resident's stretch pants and assisted the resident in pivoting to face the bed and sit in his/her wheelchair.
-When standing and pivoting the resident was hunched over and his/her knees were bent throughout the transfer.
During an interview on 5/2/24 at 6:26 A.M. CNA F said:
-Staff have to assist residents in transfers until therapy assessed them to determine if they can transfer on their own.
-Residents were supposed to wear a gait belt at all times if they can't bear full weight.
-Residents should all have a gait belt in their room.
-It was the first time he/she had ever met the resident or transferred him/her. He/She knew the resident needed staff assistance for transfers and was supposed to wear a gait belt for all transfers.
-The resident said he/she felt sick so he/she just tried to quickly transfer him/her into his/her wheelchair by grabbing the back of the resident's pants during the transfer.
During an interview on 5/2/24 at 6:52 A.M. LPN A said:
-Staff need to use a gait belt any time they help transfer a resident. There could be problems with transfers if staff weren't using a gait belt.
-The resident needed help with transfers and should have a gait belt on during all transfers.
During an interview on 5/3/24 at 2:49 P.M. CNA C said:
-Staff should always use a gait belt if they need to assist with a resident transfer.
-Gait belts should be in the drawers of each resident's bedside table or hanging on the resident's wall.
During an interview on 5/3/24 at 3:11 P.M. the Director of Therapy said:
-If a resident needs assistance with transfers the first step is to always put a gait belt on the resident.
-The resident required moderate assistance to go from a seated to a standing position and needed assistance of one staff for transferring from the bed to the wheelchair.
-Staff were to lift a little on the gait belt. The resident could currently bear about 75 percent weight and staff were to do the other 25 percent of the work.
During an interview on 5/6/24 at 9:58 A.M. RN A said:
-If a staff person was doing a one-person assist for transfers they should put on a gait belt first, place the wheelchair as close to the bed as possible and lock the wheelchair.
-Before helping the resident stand they should ask the resident if they felt dizzy. If not, they can proceed in assisting the resident to stand and transfer.
During an interview on 5/6/24 at 2:12 P.M. the DON said:
The charge nurse should call the shift manager when a resident has a fall. If they can't get hold of the on-call manager, they call him/her.
-The charge nurse adds an immediate intervention for the resident following a fall.
-The team discusses the fall and immediate intervention the following morning in clinical meeting and decides what interventions will be added into the resident's care plan.
-A root cause analysis should be done by the whole team which should be added to the fall investigation.
-The Unit Manager had been responsible for the fall investigations.
-A manager should audit to make sure fall interventions have been added into resident care plans.
-Staff assisting residents with transfers should always use a gait belt.
MO00234543
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (process of c...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys were not able to filter the blood) received ongoing assessments of the dialysis site and accurate description of resident's the dialysis site for one sampled resident (Resident #374) out of 21 sampled residents. The facility census was 105 residents.
Review of facility policy End-Stage Renal Disease (ESRD - inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), policy revised September 2010 showed:
-Residents with ESRD, would be cared for according to currently recognized standards of care.
-Type of assessments data that was to be gathered about the resident's condition on a daily or per shift basis.
A policy was requested for dialysis care was requested but the facility had no policy.
1. Review of Resident #374's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-End Stage Renal Disease.
-Dependence on renal dialysis.
Review of the resident's Order Summary Report 4/25/24 showed:
-Dialysis pre weight in the morning every Monday, Wednesday, and Friday.
-Dialysis post weight in the afternoon every Monday, Wednesday, and Friday.
-No orders for the resident to receive dialysis treatments, including location for dialysis and days for dialysis.
-No orders for site care and type of access the resident had.
-No orders for the frequency of how often the dialysis site was to be assessed.
Review of resident's base line care plan dated 4/25/24 showed:
-The resident needed dialysis management.
-Did not show when dialysis was to be performed.
-Did not show type of dialysis access.
Review of resident's Progress Notes 4/24/24 thru 5/1/24 showed:
-Note dated 4/24/24 showed the resident had a dialysis catheter to the right side of the resident's chest.
-No other progress notes showed the resident had a dialysis catheter to the right side of the resident's chest.
Observation on 4/29/24 at 11:53 A.M. of the resident showed:
-He/She was sitting in a wheelchair.
-He/She had a dialysis catheter that exited from the right side of his/her chest with a clean, dry, intact dressing.
During an interview on 5/2/24 at 9:22 A.M., the resident said:
-He/She went to dialysis three times a week.
-Staff did not assess the dialysis site.
-He/She only had the dialysis access through the catheter in his/her chest.
During an interview on 5/3/24 at 9:30 A.M. Registered Nurse (RN) A said:
-The resident was at dialysis and left before his/her shift started.
-The dialysis site was not given in report.
-He/She did not know what kind of dialysis access the resident had or where the dialysis access was located on the resident.
-The dialysis site would have been assessed before the resident left for dialysis and upon the resident's return for signs of bleeding and infection.
-The dialysis site should be assessed every shift for signs of infection and bleeding.
-The assessment should have been documented on in the computer.
-He/She was unable to produce the assessments.
-He/She said that if the assessments were not documented then he/she would have to assume the assessments were not performed.
-There should be orders to assess the site and how often, and there should be orders for when the resident goes to dialysis.
-If the orders to assess the dialysis site and when the resident had dialysis were not in the system the doctor would be called and orders obtained and documented for these items.
During an interview on 5/6/24 at 12:43 P.M., DON said:
-It was his/her expectation that a nurse would know the type of dialysis access a resident had.
-It was his/her expectation that the nurses would know how to assess the dialysis access and to chart the assessment in the computer.
-It was his/her expectation that the dialysis site would be assessed every shift.
-It was his/her expectation that the resident would have orders to assess the dialysis site, and where to send the resident for dialysis and when.
-The orders for assessment should have been placed in the computer within the first eight hours after the resident was admitted .
-The assessment should be documented on the Treatment Administration Record as being done.
-If the assessment showed any abnormal findings, there would a be nurses note stating what the abnormal finding was and the doctor's response.
-If the dialysis assessments were not documented in the computer system, then it would be assumed the assessments were not performed.
-The unit manager was responsible for auditing the dialysis orders and assessment, but the unit manager had recently quit and not been replaced.
-Ultimately he/she was responsible to the audits.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive Post Traumatic Stress Disorder (PTSD - a men...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event. Symptoms may include flashbacks, nightmares, and severe anxiety) care plan was in place and that staff were educated on ways to decrease the resident's exposure to triggers and decrease the effects of a trigger for one sampled resident (Resident # 65) out of 21 sampled residents. The facility census was 105 residents.
The facility's Trauma Informed Care process, undated, showed:
-The Abbreviated PTSD Checklist for Civilians (PCL -C), a two-item version, would be used within 72 hours of admission.
-If there were positive screen results a six-item version of the PCL-C would be completed for the resident's five-day assessment.
-Residents who have a trauma history will have access to trauma-sensitive and behavioral health treatment as appropriate.
-Staff members will need skills and guidance on identifying symptoms of trauma and acting in a trauma-responsive manner.
1. Review of Resident #65's admission Record showed he/she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with a diagnosis of PTSD.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 2/5/24 showed the resident was moderately cognitively impaired and was diagnosed with PTSD.
Review of the resident's Psychiatric Conditions care plan, initiated 2/8/24 showed:
-The resident had a history of:
--Adjustment disorder with anxiety (strong emotional or behavioral reaction to stress or trauma).
--Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
--Insomnia (difficulty falling or staying asleep or getting good quality sleep).
--PTSD.
-PTSD triggers were loud noises.
Note: There was no separate care plan specifically to address the resident's PTSD needs.
-Interventions listed were:
--Approach in calm manner.
--Encourage venting of feelings.
--Explain changes in routine and procedures.
--Help resident recall past accomplishments.
--Listen attentively to concerns and fears.
--Observe for changes in behavior and mood and consult physician as needed.
--Redirect and offer reassurance as needed.
-There was no identified history of the resident's trauma.
-There was no information on how a the resident typically reacted or how the resident's mood or behavior were affected when triggered.
-There was not a comprehensive list of what staff should do to decrease the resident's exposure to triggers that might re-traumatize him/her.
-There was no clear guidance on how staff could best decrease the effects of a trigger on the resident.
During an interview on 4/29/24 at 3:08 P.M. the resident said:
-He/She had PTSD from being in the Vietnam war.
-Triggers were:
--War and other violent and loud movies.
--[NAME].
--The 4th of July especially was a trigger.
--Talking with people sometimes triggered PTSD.
-PTSD still affected his/her life.
-He/She used to see a psychologist through the VA system for at least a couple of years. He/She didn't think he/she needed to see one now.
During an interview on 5/03/24 at 2:38 P.M. Certified Nurse Assistant (CNA) C said:
-He/She didn't know the resident was diagnosed with PTSD or what trauma he/she had experienced.
-He/She hadn't been told what might trigger the resident's PTSD or how staff would know if the resident was experiencing a trigger.
-He/She didn't know what staff were to do to decrease the likelihood of a trigger or what staff should do if the resident was triggered.
During an interview on 5/6/24 at 9:56 A.M. Licensed Practical Nurse (LPN) C said:
-He/She knew the resident was diagnosed with PTSD, but wasn't sure where he/she saw that.
-In the old electronic records system there was a PTSD assessment nurses filled out, but he/she didn't know if the assessment was in the new system.
-He/She didn't know what the resident's triggers were.
During an interview on 5/6/24 at 12:44 P.M. the Director of Nurses (DON) said:
-A PTSD care plan should show:
--All the resident's known triggers.
--What staff should do to decrease the likelihood of a trigger.
--What staff should do if the resident was triggered.
-Staff should be able to see what the resident's triggers were from their PTSD care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility considered all appropriate altern...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility considered all appropriate alternatives prior to installing bed rails for one sampled resident (Resident #6) with a history of falling from bed out of 21 sampled residents. The facility census was 105 residents.
Review of the facility's Bed Entrapment Prevention policy, dated 11/18/21 showed:
-The facility was restraint-free.
-Full, half or quarter rails were only used by rare exception and only after proper assessment.
-Bed canes (a device attached to the bed) were considered assistive devices.
Review of the facility's in-service training for bed entrapment and bed rail utilization, dated 8/4/22 showed:
-Bed rails were considered restraints and the facility didn't use them.
-Bed assist bars were enablers that allowed the resident more mobility and needed to be properly identified on the Bed Rail Observation/Assessment form since they could still potentially be an entrapment risk, depending on the resident and their assessed needs.
-Signatures of those in attendance included several nursing staff and the current Maintenance Supervisor.
1. Review of Resident #6's admission Record showed the resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included:
-Multiple Sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Muscle weakness.
-History of falling.
Review of the resident's Risk for Falls care plan, initiated 1/17/24 showed:
-The resident was at risk for falls related to his/her need for ADL assistance.
-Staff were to:
--Encourage the resident to assume a standing position slowly.
--Remind the resident not to transfer without assistance.
--Keep call light and personal items within reach.
--Provide a clutter-free environment.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 1/22/24 showed the resident:
-Had impaired vision.
-Was severely cognitively impaired.
-Was dependent on staff for transfers and Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting).
Review of the facility's Post Fall Investigation Report, dated 2/18/24 showed:
-The resident fell on 2/17/24 at 2:00 A.M.
-The resident was identified as being at risk for falls on his/her care plan.
-Planned systemic interventions/changes would be frequent rounds and a low bed.
Review of the resident's physician orders, dated 4/2/24, showed bed cane(s) for positioning and bed mobility.
Review of the resident's Fall Risk Care Plan, dated 4/5/24 showed:
-The following interventions, all dated 4/5/24:
--Anticipate and meet the resident needs.
--Remind resident to call for assistance with transfers.
--Encourage participation in activities that promote exercise and physical activity for strengthening and improved mobility.
--Keep call light and frequently used personal items within reach.
Note: There was no mention of a lowered bed, frequent rounds, or a toileting schedule. There was no intervention for bed canes.
Review of the resident's Post Fall Investigation Report, dated 4/10/24 showed:
-The resident had an unwitnessed fall in his/her room on 4/9/24 at 7:00 P.M.
-The resident was found on the floor.
-His/Her bed was in the low position.
Note: There was no mention of adding bed canes to the resident's bed.
Review of the resident's Required Devices Care Plan, initiated 4/10/24, showed:
-Partial bed rails on both sides of the bed.
-Registered Nurse(s) (RN) and/or Licensed Practical Nurse(s) (LPN) were to assess appropriateness of bed rail use and complete a Bedrail Observation/Assessment.
-CNAs and nurses were to encourage compliance with the device.
Review of the resident's Bed Rail Observation/Assessment, dated 4/23/24 showed:
-The resident's family requested the bedrails for safety reasons.
-The resident had a balance deficit, pain, and was unable to support his/her trunk in an upright position.
-The resident leaned forward and to the right and was cognitively impaired.
-He/She had a history of falling out of bed, sliding onto the floor, and acted impulsively.
-The bedrails would assist the resident in holding himself/herself on one side and would not impede his/her movement.
-Alternates attempted were a lowered bed and bedside mat.
-Bedrails were recommended when the resident was in bed due to the above-mentioned reasons and would consist of left and right upper quarter rails.
-There were no gaps between the mattress and bed rail or the bed rail and the headboard on the right or left sides of the bed.
-The bed dimensions were appropriate for the resident's size and weight based on visual inspection of the resident in bed and the resident's verbalized comfort level.
-Bed rail assessments would be completed on a quarterly basis.
-Risks, benefits, and informed consent included:
--Risks and benefits were explained to the resident and/or resident representative regarding the medical necessity for the use of bed rails and entrapment risks.
--Benefits of bed rails included increased mobility, transfers in and out of bed, supporting self during cares, repositioning, boundary identification, and providing a feeling of security.
--Risks of bed rails included risk of entrapment; skin tears, bruises, and lacerations; debility; and chest, head, or neck injury, including strangulation, suffocation, bodily injury, and death.
-The form was signed by the Director of Nursing (DON) on 5/2/24 with a hand-written note showing the resident's family member was educated by phone.
Note: There was no documentation that any other device was attempted that could have assisted the resident with boundary identification or justification why such a device would not be appropriate. There was no documentation of interventions attempted other than the lowered bed and bed mat or justification why other interventions would be ineffective or inappropriate.
Review of the resident's Fall Risk Care Plan, dated 4/28/24, showed:
-The resident's family required one-fourth bedrails for fall prevention. The family was educated regarding risk of entrapment and were informed the facility does not promote the use of bed rails. The family refused bed canes, verbalized understanding of risks, and asked for bilateral rails. Staff were educated to monitor positioning of resident and rails during rounds.
-Staff were to:
--Keep bed in the low position with brakes locked.
--Monitor for changes in condition affecting risk for falls and notify physician if observed.
--Utilize safety devices as ordered.
--Use bed rails while resident was in bed to aid in bed mobility and repositioning.
Review of the resident's physician orders on 5/1/24 showed orders for bed cane(s) for positioning and mobility were still active and there were no orders for bed rails.
Observation on 5/1/24 at 10:25 A.M. showed:
-The resident was in bed and appeared to be sleeping.
-The resident had what looked like quarter bed rails covered with linens or fabric on both sides. A pillow was against one rail beside the left side of the resident's head and bedding was near the right side of the resident's head, hiding the details of the bed rails.
Observation on 5/2/24 at 6:08 A.M. showed the resident was in bed with his/her quarter bed rails up. The rails were covered with linens on both sides.
During an interview on 5/2/24 at 7:12 A.M. Family Member A said:
-The resident had a fall from the bed in February and fractured his/her ankle and fell from the bed again in April and got a bruised and swollen area to his/her head.
-He/She believed the only way to keep the resident safe was to use bed rails.
During an interview on 5/3/24 at 2:40 P.M. Certified Nurse Aide (CNA) C said:
-The resident had bed rails because his/her family member requested it.
-The resident tended to place his/her upper body close to the edge of his/her bed facing the hallway door.
-Before the bed rails were used the facility lowered the resident's bed. After the resident's first fall a fall mat was used beside the bed when occupied. The resident also had U-shaped grab bars attached to his/her bed which were taken off when the rails were installed. Those were the resident's only interventions prior to the bed rails.
-The resident was able to grab both the U-shaped bars and the bed rails to assist in turning.
-He/She had never seen the facility use any other interventions prior to the bed rails being installed. The resident never had a parameter mattress (a mattress with slightly raised edging, usually made of foam, typically with an open mid-section allowing egress) or any other device or method to help the resident identify where the edge of his/her bed was and had never used a larger bed.
-The resident had the bed rails for about two weeks.
During an interview on 5/3/24 at 3:00 P.M. the Director of Rehabilitation said:
-The resident received therapy services off and on since his/her original admission date.
-Therapy provided maximal assistance (staff does more than half the effort) when the resident sat on the side of his/her bed.
-The resident had always used bed canes for repositioning in bed.
-The Rehabilitation Department had not recommend bed rails and was not involved in the resident's bed rail assessment.
-Nursing would have recommended the bed rails.
During an interview on 5/3/24 at 3:35 P.M. the Director of Nursing (DON) said:
-The facility told the resident's family they would not allow the bed rails, but they kept insisting after the resident's second fall.
-The resident's family member said he/she was going to buy a bed rail on-line and install it himself/herself. That was why the facility had the Maintenance Supervisor install the rails. He/She thought that would be safer than something the family brought in.
-NOTE: The physician's order and the Bed Rail assessment was for bed mobility and positionings, not as a fall precaution intervention.
During an interview on 5/6/24 at 11:38 A.M. Licensed Practical Nurse (LPN) C said:
-Fall interventions he/she was aware of included a lowered bed after the resident's fall in February and at some point a fall mat was added.
-In April the bed rails were added.
-NOTE: The physician's order and the Bed Rail assessment was for bed mobility and positionings, not as a fall precaution intervention.
During an interview on 5/6/24 at 12:44 P.M. the DON said:
-Prior to bed rails being installed nursing was responsible for assessing the resident for appropriateness of the bed rails. This included an assessment of benefits and risks for the resident.
-Interventions attempted prior to the use of bed rails should be identified and there should be documentation why those interventions were not appropriate or enough.
-The resident's family was educated on the benefits and risks of bed rails.
-A lowered bed was put in as an intervention for the resident prior to the use of bedrails. The resident's family did not think it was enough and thought only bed rails could prevent the resident from falling.
-NOTE: The physician's order and the Bed Rail assessment was for bed mobility and positionings, not as a fall precaution intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #6) with bed ra...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #6) with bed rails had rails that were compatible with the bed and were installed and maintained in a safe manner out of 21 sampled residents. The facility census was 105 residents.
Review of the facility's Bed Entrapment Prevention Policy, dated 11/18/21 showed:
-The facility's goals were:
--Improved bed safety.
--Mitigating the risk of entrapment.
--Testing bed rails across all seven potential zones of entrapment.
-Full, half, or quarter rails were only used by rare exception.
Review of the facility's Bed Entrapment/Bed Rail Utilization training report, dated 8/4/22, showed:
-A hospital bed manufacturer's Bed Entrapment diagram and information, dated 2009, was part of the training. The manufacturer's information referenced the Food and Drug Administration (FDA) Hospital Bed Safety webpage.
-Signatures for the training included several nursing staff and the facility's current Maintenance Supervisor.
1. Review of Resident #6's admission Record showed the resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included:
-Multiple Sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Muscle weakness.
-History of falling.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 1/22/24 showed the resident:
-Had impaired vision.
-Was severely cognitively impaired.
-Was dependent on staff for transfers and Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting).
Review of the resident's physician orders, dated 4/2/24, showed bed cane(s) (a device attached to the bed for grasping) for positioning and bed mobility.
Review of the resident's Required Devices Care Plan, initiated 4/10/24, showed partial bed rails on both sides of the bed.
Review of the resident's Bed Zone Measurement Log, dated 4/23/24 and completed by the Maintenance Supervisor, showed:
-The bed manufacturer's Bed Entrapment information, dated 2009, referencing the FDA's Hospital Bed Safety webpage was used as a reference for installing the bed rails.
-Measurements for all zones were recorded on the form.
-The bed manufacturer's instructions for Zone Six (the space between the end of the rail and the side edge of the head or foot board) showed the space presented a risk of entrapment.
-The facility's form showed Zone Six gaps should be less than two and three-eighths inches or greater than twelve and one-half inches.
-Documentation was hand written on the form showing Zone Six measured three-fourth's inch.
Review of the resident's Bed Rail Observation/Assessment, dated 4/23/24 showed:
-The resident's family requested the bedrails for safety reasons.
-Bedrails were recommended when the resident was in bed.
-There were no gaps between the mattress and bed rail or the bed rail and the headboard on the right or left sides of the bed.
-Risks of bed rails included risk of entrapment: skin tears, bruises, and lacerations; debility; and chest, head, or neck injury, including strangulation, suffocation, bodily injury, and death.
-The form was signed by the Director of Nursing (DON) on 5/2/24 with a hand-written note the family member was educated by phone.
Review on 5/1/24 of the resident's physician orders showed orders, dated 4/2/24, for bed cane(s) for positioning and mobility and there were no orders for bed rails.
Observation on 5/1/24 at 10:25 A.M. showed:
-The resident was in bed and appeared to be sleeping.
-The resident had quarter bed rails covered with linens or fabric on both sides. A pillow was beside the left side of the resident's head and bedding was near the right side of the resident's head, hiding the details of the bed rails.
Observation on 5/2/24 at 6:08 A.M. showed the resident was in bed with his/her quarter bed rails up. The rails were covered with linens on both sides.
During an interview on 5/3/24 at 2:40 P.M. Certified Nursing Assistant (CNA) C said:
-The resident had the bed rails for about two weeks.
-Maintenance installed the bed rails.
-If staff noticed problems with the rails they were to report it to the charge nurse or Maintenance Supervisor.
-He/She hadn't noticed any safety issues with the resident's rails.
Observation on 5/3/24 at 3:20 P.M. showed:
-The resident's bed had been stripped of all bedding and the resident's quarter rails were on the bed.
-The seven bed rail entrapment zones were measured and Zone Six measured seven and one-half inches between the end of the rail and the headboard. (Note: According to the facility's Bed Zone Measurement Log guidance, Zone Six spacing should be less than two and three-eighths inches or over twelve and one-half inches.)
-The bed rail had a metal lever that when lifted caused the rail to fall quickly and with force. The lever was on the outside of the rail near the level of the bed's mattress frame. There were several vertical bars on the rail. There were five spaces in the middle section of the rail that measured two and one-eighth inches and four spaces (two on either end of the bar) that measured three and one-fourth inches. The surveyor could put his/her hand and forearm through the bar spaces where the release lever could be accessed if someone was in bed.
-The bed rail was secured to the bed by an adjustable tightening knob located near the mattress frame. The knob had been loose upon observation and the entire bed rail could be moved in a circle to the right or the left.
-There were no observations of the rail being loose when the resident was in the bed; however, the knob could easily be loosened by staff, visitors, or a person while in the bed. With the rail loose the spacing between the rail frame and mattress changed and posed a risk for entrapment. The rail would not have provided repositioning support for the resident when loose.
-The Director of Nursing (DON) was shown the spacing, release lever, and knob adjustability observations and said the bed rail was not safe.
During an interview on 5/3/24 at 3:35 P.M. the DON said:
-The resident's family member said he/she was going to buy a bed rail on-line and install it himself/herself.
-That was why the facility had the Maintenance Supervisor install the rails.
During an interview on 5/6/24 at 11:38 A.M. Licensed Practical Nurse (LPN) C said:
-The resident's bed rails were installed in April.
-Staff had not reported any problems with the bed rails.
During an interview on 5/6/24 at 12:44 P.M. the DON said:
-The Maintenance Supervisor:
--Was responsible for installing the bed rail and making sure it was safe for use.
--Was trained on the Bed Entrapment Prevention policy and entrapment risks.
--Had information on measurements for installing the bed rail.
-Bed rails should be compatible with the bed when installed.
-Nursing should observe the bed rails each shift. If the rails didn't feel stable or if spacing wasn't safe they should notify the Maintenance Supervisor.
During an interview on 5/6/24 at 1:27 P.M. the Maintenance Supervisor said:
-He/She had been trained on installing bed rails.
-He/She had access to the bed rail policy and information on appropriate bed rail spacing.
-He/She had to measure and document spacing for the bed entrapment zones, including spacing within the bed rail, between the mattress and bed rail and between the rail end and the headboard.
-He/She was surprised at how loose the bed frame was on 5/3/24. He/She hadn't installed it that way.
-Staff might have loosened the bars and should be educated to not leave the bed rails loose.
-He/She didn't do audits on bed rail safety. He/She relied on nursing staff to report if the bed rail was loose or if there were other problems. He/She was responsible for fixing any issues with bed rails or grab assist bars.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the commode risers (assistive devices to imp...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the commode risers (assistive devices to improve the accessibility of toilets to older people or those with disabilities. They can aid in transfer from wheelchairs and may help prevent falls) in resident rooms [ROOM NUMBERS] in an easily cleanable condition. The facility also failed to maintain three mechanical lifts on the 300 Hall and three mechanical lifts on the 400 Hall in sound condition. This practice potentially affected 12 residents, who resided on the 300 and the 400 Halls, who depended on mechanical lifts for transfers and two residents who used commode risers. The facility census was 105 residents.
1. Observation with the Maintenance Director on 4/30/24, showed:
-At 10:17 A.M., there was an area on the commode riser in resident room [ROOM NUMBER] that was not easily cleanable.
-At 11:52 A.M., there was a crack in the commode riser in resident room [ROOM NUMBER].
During an interview on 5/10/24 at 12:59 P.M., the Maintenance Director said that he/she checked the commode risers every month but he/she has not documented the checks. The Certified Nursing Assistants (CNAs) also should be checking as well.
2. Review of a list provided by the Director of Nursing (DON) and reviewed on 5/3/24, showed there were 10 residents who resided on the 400 Hall who used mechanical lifts and six residents who resided on the 300 Hall who used mechanical lifts.
Observations on 5/3/24 at 10:55 A.M., showed the mast (the metal part of the mechanical lift which attached the base of the lift to the boom (the part of the lift with a cradle to lift a dependent resident), of the mechanical lift on 400 Hall, was very loose at the area where the mast was attached to the base.
During an interview on 5/3/24 at 10:59 A.M., CNA A said he/she had not noticed the lift on the 400 Hall was loose on that day.
During an interview on 5/3/24 at 11:02 A.M., Restorative Aide (RA) A said he/she had not noticed the lifts on 400 Hall was loose earlier that day.
During an interview on 5/3/24 at 11:05 A.M., CNA B said he/she had not noticed the mechanical lift being loose on the morning of 5/3/24.
Observations on 5/3/24 at 11:09 A.M., showed the lift outside resident room [ROOM NUMBER] was loose.
During an interview on 5/3/24 at 11:12 A.M., CNA C said he/she used the lifts outside resident room [ROOM NUMBER] but had not noticed the mast of that lift was loose.
During an interview on 5/3/24 at 11:14 A.M., Licensed Practical Nurse (LPN) B said;
-He/She used the mechanical lift outside resident room [ROOM NUMBER], but he/she did not notice that the mast was loose.
-He/She expected facility staff to place issues pertaining to the lifts in the work order book.
-Facility staff should place a sign on the lift which stated DO NOT USE and place the lift in the shower room.
During an interview on 5/3/24 at 1:56 P.M., the DON said the following about the lifts:
-If the screws on the lifts were loose, the lift may be a little wiggly.
-Facility staff should notify the Maintenance Director any mechanical lifts that may not be in good repair.
-He/She expected facility staff to place a sign on the lift to let other staff know that the lift should not be used.
-He/She expected facility staff to place the lift in the service hall so that other staff would not use it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to observe the resident while he/she took his/her medicat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to observe the resident while he/she took his/her medications, left the medications on the resident's bedside table for one sampled resident (Resident #88), and to assess the resident for safety of self-administering medications for three sampled residents (Resident #88, #6, #71) out of 21 sampled residents. The facility census was 105 residents.
Review of the facility's policy titled Self-Administration of Medications dated 1/1/19 showed:
-An assessment should be conducted by a member of the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out the responsibility of self-administration of medications.
-A skills assessment should be conducted quarterly or if needed when there was a change in condition.
Review of the facility's policy titled Bedside Medication Storage dated 1/1/19 showed there should be a written order for the bedside storage of medication.
1. Review of Resident #88's admission record (printed on 5/2/24) showed:
-The resident had been a resident at the facility for about one and a half years.
-Some of the resident's diagnoses included depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life), bipolar disorder (a disorder characterized by extreme mood swings from depression to mania), hemiplegia (paralysis of one side of the body) affecting his/her dominant side, diabetes (a deficiency or complete lack of insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) secretion in the pancreas or resistance to insulin) with use of insulin, and high blood pressure.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) dated 2/5/24 showed the following staff assessment of the resident:
-Taking high risk medications including insulin, an antipsychotic (to stabilize episodes of mania in people with bipolar disorder) medication, an antidepressant, a diuretic (a medication used to treat heart-related conditions by helping the body get rid of unneeded water and salt through increased urination which helps lower blood pressure and helps make it easier for the heart to pump), an antiplatelet (a group of medicines that stop blood cells (called platelets) from sticking together and forming a blood clot) medication, and a hyperglycemic (medication to treat high sugar (glucose) in your blood) medication.
-Cognitively intact.
Review of the resident's care plan dated as revised on 2/19/24 showed:
-The resident had cognitive deficits such as forgetfulness and short-term memory deficits.
-The resident required minimum to moderate assistance with daily decision making.
-Some of the resident's diagnoses included bipolar disorder and depression.
-There was nothing in the care plan about self-administration of medications or keeping any medications at bedside.
Observation on 4/29/24 at 10:59 A.M. showed the resident was lying in bed and a medication cup with more than four pills was on the resident's overbed tray.
During an interview on 4/29/24 at 10:59 A.M., the resident said:
-He/She was asleep when staff brought his/her medication, so the staff left the cup of pills on his/her overbed tray.
-The staff leave his/her pills in a cup for him/her all the time.
Review of the resident's Medication Administration Record (MAR) dated April 2024 showed:
-Some of the resident's physician's orders included medications for depression, high blood pressure, diabetes, and bipolar disorder.
-A physician's orders for refresh tears solution for dry eyes.
Review of the resident's Physician's Order Sheet (POS) dated May 2024 showed no order for self-administration of medications.
Review of the resident's medical records showed no assessment or physician's order for self-administration or bedside storage of medication.
Observation on 5/2/24 at 5:13 A.M. and on 5/3/24 at 10:14 A.M. showed there was an empty medication cup on the resident's overbed tray.
During an interview on 5/3/24 at 10:23 A.M., Certified Nursing Assistant (CNA) A said:
-He/She had not seen medications at the resident's bedside.
-The nursing staff should not leave medications at the resident's bedside.
During an interview on 5/3/24 at 1:43 P.M., Registered Nurse (RN) B said:
-He/She had not seen medications sitting out in the resident's room.
-They should not have left medications in the resident's room.
During an interview on 5/3/24 at 3:14 P.M., Certified Medication Technician (CMT) B said:
-The resident could only have his/her eye drops at bedside.
-The resident had not asked him/her to leave his/her medications at bedside.
Observation on 5/6/24 at 9:19 A.M. showed:
-The resident was lying in bed.
-Eye drops and an empty medication cup were on the resident's overbed tray.
During an interview on 5/6/24 at 12:43 P.M., the Director of Nursing (DON) said:
-The interdisciplinary team should first talk about whether the resident was suitable for leaving medications at the bedside and self-administering them.
-If they determined the resident might be capable of administering his/her own medications, they would have to do an assessment.
-If it was determined through the assessment that the resident could administer his/her own medication, they would need to get a physician's order.
-The resident had not been assessed for self-administration of medications.
2. Review of Resident #6's admission Record showed the resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that include dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
Review of the resident's admission MDS dated [DATE] showed the resident:
-Had impaired vision and couldn't see regular newsprint.
-Was severely cognitively impaired.
Review of the resident's Order Review Report showed an order, dated 4/2/24 for May keep OTC medications at bedside.
Review of the resident's medical record showed no self-administration of medication assessment had been completed.
Review of the resident's Comprehensive Care Plan on 5/1/24 showed no self-administration of OTC medications care plan had been added and no other individual care plan mentioned self-administration of OTC medications.
During an interview on 5/03/24 at 2:30 P.M., CNA C said:
-The resident required total care from staff and didn't do anything for himself/herself at this time.
-The resident had dementia and wouldn't be able to self-administer medications of any kind.
During an interview on 5/6/24 at 9:48 A.M. Licensed Practical Nurse (LPN) C said:
-Self-administration of OTC medications would not be appropriate for the resident because he/she was confused and wouldn't even be considered a candidate for that.
-The resident would have to have the capacity to know what medication he/she was taking, know the appropriate amount to use and how to use or take the medication, and when it would be appropriate to take it. The resident was not capable of knowing that.
-The resident could always get medication as-needed from the nurse.
3. Review of Resident #71's admission Record showed he/she was readmitted to the facility on [DATE] with the following diagnoses:
-Dementia.
-Wandering.
Review of the resident's quarterly MDS, dated [DATE] showed:
-The resident was visually impaired and couldn't see regular newsprint.
-The resident was severely cognitively impaired.
Review of the resident's Order Review Report showed an order, dated 4/1/24 for May keep OTC medications at bedside.
Review of the resident's medical record showed no self-administration of medication assessment had been completed.
Review of the resident's Comprehensive Care Plan on 5/1/24 showed no self-administration of OTC medications care plan had been added and no other individual care plan mentioned self-administration of OTC medications.
During an interview on 5/3/24 at 2:28 P.M. CNA C said the resident couldn't safely self-administer OTC medications because he/she had dementia and was confused.
4. During an interview on 5/6/24 at 9:45 A.M. LPN C said:
-There was nobody at the facility who self-administered OTC medications.
-The facility would need to do an assessment to make sure the resident could self-administer safely. The DON would be involved in the assessment process and the resident would need to have a physician order for it. Residents would be evaluated for each medication they were able to safely self-administer and only those specific medications would be indicated on the resident's orders for self-administration.
-There was a checkbox on the electronic medical record orders for May have OTC meds at bedside. He/She thought that had been clicked by mistake for Residents #6 and #71.
-Neither resident was appropriate for self-administration of OTC medications, and both residents were incapable of using OTC medications safely and as indicated.
During an interview on 5/6/24 at 12:44 P.M. the DON said:
-Prior to self-administering any medication the resident would need to be assessed for his/her ability to do so safely, and the specific medication they could self-administer would be identified on the orders.
-On the electronic medical system there was a box for resident orders where nurses could click all for all generic orders. May keep OTC medication at bedside was one of those orders. After clicking all nurses would need to re-click on the orders they want to get rid of.
-He/She thought the order was clicked by mistake for Residents #6 and #71. That was not an appropriate order for either of the residents due to their cognition. Neither resident could safely self-administer any OTC medication.
-Managers were responsible for auditing the residents' orders and ensuring accuracy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to make pureed (cooked food, that has been ground, presse...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to make pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs in a palatable manner and to maintain hot foods on room trays during the breakfast meal, at or close to 120 ºF (degrees Fahrenheit) when those trays were delivered to the residents. This practice potentially affected at least six residents who resided on the 300 Hall. The facility census was 105 residents.
1. Review of the undated recipe for pureed eggs showed:
-Boil eggs for three minutes and allow to sit in the water covered for 20 minutes.
-Remove eggs from water and immerse in cold water to cool.
-Crack shells and rinse well with water to remove all shells.
-For puree diets, prepare items per regular recipe. Portion number of servings needed based on diet census and puree. Refer to therapeutic menu for appropriate portion size of puree foods.
-There were no seasonings such as salt or any spices that were mentioned in this recipe.
Observations on 5/2/24 from 6:25 A.M. through 6:31 A.M., during the breakfast meal preparation, showed:
-The Dietary Manager (DM) placed four boiled eggs into the food processor.
-The DM did not have a recipe book open at the time.
-The DM added an unmeasured amount of butter to the boiled eggs.
-The DM processed the boiled eggs with the butter in the food processor to a pureed consistency
Observation on 5/2/24 at 7:42 A.M., showed the pureed eggs were not flavorful.
During an interview on 5/2/24 at 7:44 A.M., the DM said the following after he/she tasted the pureed eggs:
-He/She has not asked the Registered Dietitian (RD) for any kind of flavor enhancements.
-He/She had not tasted the pureed eggs before that day.
During a phone interview on 5/13/24 at 11:01 A.M., the Consultant Registered Dietitian (RD) said:
-He/She was at the facility twice per week.
-He/She he has tried some of the pureed products, but not regularly.
-He/She does not eat eggs or dairy products.
-When they (he/she and the Dietary Manager) discussed the taste of pureed foods before, they just want salt and pepper at the table.
-The residents do not want a bland egg.
2. During the resident group interview on 4/30/24 at 10:32 A.M., the residents who attended said the food was served cold.
Observation on 5/2/24 from 8:03 A.M. through 8:19 A.M., showed Certified Nursing Assistant (CNA) E delivered room trays to residents in the following rooms:
-At 8:03 A.M., he/she delivered a room tray to resident room [ROOM NUMBER].
-At 8:05 A.M., he/she delivered a room tray to resident room [ROOM NUMBER].
-At 8:06 A.M., he/she delivered 2 room trays to resident room [ROOM NUMBER].
-At 8:08 A.M., he/she delivered a room tray to resident room [ROOM NUMBER]
-At 8:09 A.M., he/she delivered a room tray to resident room [ROOM NUMBER].
-At 8:10 A.M., he/she delivered a room tray to resident room [ROOM NUMBER]
-At 8:13 A.M., he/she delivered a room tray to resident room [ROOM NUMBER]
-At 8:13 A.M., CNA E left from resident room [ROOM NUMBER] to where the cart was at room [ROOM NUMBER] to get a a cup of coffee for the resident in resident room [ROOM NUMBER]
-At 8:17 A.M., CNA E delivered a room tray to resident room [ROOM NUMBER]
-At 8:19 A.M. the temperature of the sausage on the test tray was measured in front of CNAs D and E showed:
--The temperature of the sausage was 115.7 ºF.
--The temperature of the scrambled eggs was 115 ºF.
-At 8:23 A.M., the temperature of the mechanical sausage on another tray that was for a resident who was no longer at the facility, was 95.9 ºF.
During an interview on 5/2/24 at 8:23 A.M., CNA E said there were too many trays on the food cart at once.
During an interview on 5/2/24 at 8:27 A.M., CNA C said he/she has not seen anyone from dietary department check the temperatures of room trays.
During an interview on 5/2/24 at 8:29 A.M., CNA D said he/she has not seen anyone from the dietary department check the temperatures of foods on the room trays except for one time.
During an interview on 5/2/24 at 8:45 A.M., CNA E said he/she has not seen anyone from dietary department check the temperatures of foods on trays for the 300 Hall.
During an interview on 5/2/24 at 8:58 A.M., the DM said:
-There were 18 room trays for the 300 Hall.
-The Registered Dietitian (RD) used to measure the temperature of test trays but has not done so in a while.
3. Review of Resident #56's quarterly Minimum Date Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 4/17/24 identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of 15.
During an interview on 5/2/24 at 10:19 A.M., the resident said:
-The food was cold for all meals.
-He/She received a room tray, and he/she did not go to the dining room.
4. Review of #36's quarterly MDS dated [DATE], identified the resident as cognitively intact with a BIMS score of 15.
During an interview on 5/2/24 at 10:21 A.M., the resident said the food was always cold at all three meals and he/she just want the meals to be better.
5. Review of Resident #375's Admission's MDS dated [DATE], identified the resident as having moderate cognitive impairment, with a BIMS score of 11.
During an interview on 5/2/24 at 10:29 A.M., the resident said:
-The food temperatures have not been warm enough.
-Sometimes the food arrived to him/her a little cool because of the time it took to get the food from the kitchen to his/her room, because his/her room was far from the kitchen.
6. Review of Resident #374's Admission's MDS dated [DATE] identified the resident as cognitively intact with a BIMS score of 14 of 15.
During an interview on 5/2/24 at 10:32 A.M. the resident said that the breakfasts and dinner meals were the meals that were mostly cold.
7. During a phone interview on 5/13/24 at 11:01 A.M., the Consultant Registered Dietitian (RD) said:
-He/She was at the facility twice per week.
-He/She has not gotten with the Dietary Manager about testing the temperatures of room trays.
-He/She did not get involved with the testing the temperatures of the foods.
-The residents eating in their rooms should have appropriate temperature.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure that food in the resident use refrigerator was labeled and resident's name and the date the food item was brought in in...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure that food in the resident use refrigerator was labeled and resident's name and the date the food item was brought in in accordance with the facility's policy. This practice potentially affected an unknown number of residents who have foods brought in by visitors. The facility census was 105 residents.
Review of the facility's policy entitled Safe Food Handling for Food Brought in From Outside Sources, dated 11/17, showed:
-Food and/or beverages brought into the healthcare center from the outside will be monitored by center partners for contamination, spoilage, and overall food safety.
-Food and/or beverage items brought into the center should be securely packaged and labeled with the patient's name and the date the item(s) were brought into the center. The center should have large zip type storage bags and markers, or other appropriate supplies, available for packaging, labeling and identifying food brought in from an outside source.
-Food or beverage items will be monitored and discarded by the center as follows: Perishable foods will be discarded within three days, or per manufacturer's Use by or Best by or expiration date.
-Note: If a food or beverage item appears to be spoiled, contaminated or unsafe, the item will be discarded by the center regardless of the specified use by date.
-Cold food items must be stored in a refrigerated unit to maintain an appropriate cold temperature; frozen food items must be stored in the freezer and maintained frozen solid.
1. Observation on 5/2/24 from 9:51 A.M. through 10:01 A.M., showed the following in the resident use refrigerator:
-An expired bottle of Italian flavored salad dressing, ranch dressing, mayonnaise, coffee creamer, relish, restaurant sauce, all of which were not labeled with a resident's name, or the date those containers were brought in.
-Three containers of unidentified food which were not labeled with a resident's name or the date those containers were brought in.
-One cup of an unidentified item which was not labeled with resident's name or the date that item was brought in.
-A bag of corn dogs which was not labeled with a resident's name or the date that item was brought in.
-Numerous containers of dietary supplements.
During an interview on 5/2/24 at 10:01 A.M., Licensed Practical Nurse (LPN) C said every item in the refrigerator needed to be labeled with a name of the resident for whom the food item was for, the date the item was brought in, and there was a separate refrigerator for supplements.
During an interview on 5/2/24 at 10:08 A.M., the 300 Hall Unit Manager said he/she has notified the housekeeping employees to clean the refrigerator in the past.
During an interview on 5/2/24 at 10:10 A.M., the Housekeeping Supervisor said the resident food use refrigerator should be cleaned twice per week and ideally, the housekeeper should see the expired items if the refrigerator was being cleaned regularly.
During an interview on 5/2/24 at 10:14 A.M., Housekeeper A said he/she normally cleaned the refrigerator every other Saturday but not recently.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure hand hygiene, use of a barrier for supplies an...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure hand hygiene, use of a barrier for supplies and cleansing of the glucometer during blood glucose monitoring (a blood sugar reading obtained from a small sample of blood from the finger) and administration of insulin (mediation that helps blood sugar enter the body's cells for use as energy) for three sampled residents (Resident #68, #91, and #39) out of 21 sampled residents and to ensure a policy to ensure staff correctly sanitized the glucometer between use for residents. The facility census was 105 residents.
Review of the facility Hand Hygiene policy, updated August 2021 showed:
-Hand hygiene included both handwashing with soap and water and use of alcohol-based products (gels, rinses, foams) that do not require the use of water.
-In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal (ability to kill germs) activity, reduced drying of the skin, and convenience; the exception is in the case of spore forming (microorganisms that produce dormant bodies that can reproduce even after exposure to antimicrobial agents), which require soap and water with friction.
-Provide hand hygiene before and after contact with each resident, after toileting, smoking or eating, and before and after removal of gloves.
Review of the facility Blood Glucose Monitoring Systems policy, undated showed:
-Wash hands.
-Put on gloves.
-Clean blood glucose meter with wipe, keep wet for two minutes, do not put in pocket or case. Note: The instruction did not specify what type of wipe to use, for example a product or wipe that is effective against microorganisms on surfaces.
-Remove gloves.
-Wash hands.
-Put on gloves.
-Obtain blood sample.
-Remove gloves.
-Wash hands.
-Put on gloves.
-Clean blood glucose meter with wipe then return to case. Note the instruction did not specify to keep the glucometer wet for two minutes.
-Remove gloves.
-Wash hands.
1. Review of Resident #68's Face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of diabetes (a disease of inadequate control of blood sugar).
Review of the resident's May 2024 Physician's Orders Sheet (POS) showed Novolog (medication that manages your blood sugar levels) Injection Solution 100 units per milliliter (mL), inject per sliding scale (progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges), subcutaneously (under the skin) with meals, dated 4/4/24.
Observation on 5/2/24 at 7:40 A.M. showed:
-Without first sanitizing his/her hands, Registered Nurse (RN) C entered the resident's room and placed a storage tray with supplies on the resident's bed without placing a barrier on the resident's bed.
-Without first sanitizing his/her hands, he/she put on gloves and completed the resident's Accu check with supplies from the storage tray.
-He/She then left the resident's room with the storage tray, placed the storage container lancet (sharp used for obtaining a drop of blood) in the sharp container on the medication cart, removed his/her gloves and recorded the resident's blood glucose level in the resident's electronic medical record (EMR).
-Without first sanitizing his/her hands, he/she returned to the resident's room and again placed the storage tray on the resident's bed without using a barrier.
-Then without sanitizing his/her hands, he/she put on gloves, removed the resident's insulin pen from the storage tray, wiped the top of the insulin pen with an alcohol wipe, put a needle on the tip of the insulin pen, wiped the resident's skin with an alcohol wipe and injected the resident's insulin.
-He/She then exited the resident's room with the resident's insulin pen and the storage tray.
-He/She placed the storage tray on top of the medication care without using a barrier, placed the needle in the sharp's container, removed his/her gloves, did not sanitize his/her hands and charted the resident's insulin injection in his/her EMR.
-Then without sanitizing his/her hands he/she proceeded to the next resident's care.
2. Review of Resident #91's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of diabetes.
Review of the resident's May 2024 POS showed NovoLog inject as per sliding scale with meals.
Observation on 5/2/24 at 7:40 A.M. showed:
-Without first sanitizing his/her hands, RN C entered the resident's room and placed a supply tray with on the resident's bed without placing a barrier on the resident's bed.
-Without first sanitizing his/her hands, he/she put on gloves, wiped the top of the resident's insulin pen with alcohol and placed a needle on the resident's insulin pen, wiped the resident's ski with alcohol and completed the resident's insulin injection.
-He/She then removed the storage tray from the resident's bed, entered the resident's bathroom, placed the supply tray on the resident's shower chair, removed his/her gloves and washed his/her hands.
-He/She then left the resident's room, placed the supply cart on top of the medication cart, disposed of the resident's insulin pen needle in the sharp's container and recorded the resident's insulin injection in his/her EMR.
-Then the 400 Hall Unit Manager placed a container of hand sanitizer on top of the medication cart and instructed RN C to sanitize the blood glucose meter, opened the bottom drawer of the medication cart and finding no disinfectant wipes left the area to get disinfectant wipes, returned and instructed RN C to use the disinfectant wipes on the glucose meter and wait five minutes before using the glucose meter.
-RN C sanitized the blood glucose meter with a disinfectant wipe, placed the meter first on top of the medication cart without using a barrier and then placed the glucose meter in the supply cart, sanitized his/her hands and proceeded to the next resident without waiting five minutes after having sanitized the glucose meter.
3. Review of Resident #39's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of diabetes.
Review of the resident's May 2024 POS showed Fingerstick (Accu check) blood sugar every morning and at bedtime for diabetes.
Observation on 5/2/24 at 7:53 A.M. showed:
-RN C went to the 400 Hall dining area and propelled the resident to a resident's room other than his/her room.
-He/She placed the supply tray on the first night stand without a barrier, and without first sanitizing his/her hands, put gloves on, wiped the resident's finger with an alcohol wipe, completed the resident's blood glucose monitoring, propelled the resident back to the dining room, placed the supply cart on top of the medication cart without using a barrier, discarded the lancet in the sharps container, removed his/her gloves and without first sanitizing his/her hands, documented the resident's blood glucose in his/her EMR.
4. During an interview on 5/2/24 at 8:01 A.M. RN C said:
-He/She had not washed his/her hands as he/she was supposed to have when he/she completed Resident #68's Accu check and insulin, Resident #91's insulin injection and Resident #39's Accu check, had not used a barrier for supplies and had not sanitized the glucose meter after use for Resident #68.
-He/She was aware he/she was supposed to wash his/her hands before each resident's care, after completing Accu checks, before and after insulin injections and after completing care for resident's.
-He/She had hurried and had been nervous.
During an interview on 5/2/24 at 8:07 A.M. the 400 Hall Unit Manager said:
-RN C had been nervous.
-He/She had just provided education with RN C to get him/her back on track.
During an interview on 5/3/24 at 11:21 A.M. the 400 Hall Unit Manager said:
-The Director of Nursing (DON) had him/her do education that morning with RN C regarding handwashing, and infection control with Accu checks and insulin injections.
During an interview on 5/6/24 at 12:45 P.M. the DON said:
-He/She expected staff to complete hand hygiene before starting to do any resident care, during resident care as indicated for going from clean to soiled and after resident care.
-He/She expected staff to sanitize the blood glucose monitor after use and allow it to stay wet for the duration specified on the disinfectant wipe label and store the meter in the medication cart for next use; each care used for insulin administration should have two blood glucose monitors so that there is a cleansed meter always ready for use.
-The licensed nurse completing blood glucose monitoring and insulin administration should roll the cart to the resident's room before starting and should use a Styrofoam plate for a barrier for the blood glucose monitor, Accucheck supplies and for insulin pens and needles.
-After completing an Accucheck, the licensed nurse should dispose of the lancet in the sharps container on the medication cart, remove his/her gloves, use hand sanitizer, enter the resident's blood glucose in the resident's EMR, check the physician's order for the resident's insulin, sanitize his/her hands, gather the insulin pen, needle, and alcohol wipe, place then on a barrier, return to the resident's room, sanitize his/her hands, put on gloves and administer the resident's insulin, return to the medication cart, remove his/her gloves, return supplies to the medication cart, chart the insulin administration in the resident's EMR and sanitize his/her hands.
-During new employee orientation, licensed nurses are trained on hand hygiene and infection control with Accuchecks and insulin administration.
-Licensed nurses were observed about every three months by the Unit Managers or by other management nurses.
-He/She had the 400 Hall Unit Manager do training with RN C.
-When a problem is identified, and inservice was conducted, annual training was conducted, and random observations were done by licensed nurse management staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to remove grime from the top of the garbage disposal (a device, installed under a kitchen sink between the sink's drain and the trap used to shr...
Read full inspector narrative →
Based on observation and interview, the facility failed to remove grime from the top of the garbage disposal (a device, installed under a kitchen sink between the sink's drain and the trap used to shred food waste into pieces small enough--less than 2 mm -- in diameter, to pass through plumbing); to remove a buildup of grime and debris including drinking cups from under the ice machine; to remove debris from around the nozzles of the juice machine; to ensure that Dietary Aide's (DA) A's hair was fully covered; to place a label to identify an unknown substance that was in a bottle on the shelf above the stove; to label a white powdery substance in a container in a dry goods' storage to identify that item; and to maintain the milk at 400 Hall kitchenette at a temperature of 41 ºF (degrees Fahrenheit) or colder. This practice potentially affected all residents. The facility census was 105 residents.
1. Observation on 4/29/24 from 9:11 A.M. through 9:36 A.M., during the initial kitchen observations, showed:
-A buildup of grime under the dishwasher.
-A small leak from the garbage disposal.
-A buildup of grime and debris including cups and dust under the ice machine.
-The presence of grime around nozzles of juice machine.
2. Observations on 5/2/24 from 6:25 A.M. through 8:37 A.M., showed:
-A buildup of grime under the dishwasher.
-A small leak from the garbage disposal.
-A buildup of grime and debris including cups and dust under the ice machine.
-The presence of grime around nozzles of juice machine.
-The presence of dust on light fixtures above the steam table.
-DA A's hair was not completely covered by a hair restraint.
-The temperature of the milk that was in a tub was 48.3 ºF (degrees Fahrenheit).
During an interview on 5/2/24 at 7:43 A.M., DA A said he/she did not know the lower part of his/her hair was not covered by the hair net.
During an interview on 5/2/24 at 8:39 A.M., DA B said he/she did not check the temperature of the milk before that day and the tub that the container of milk was in did not have ice in it.
During interviews on 5/2/24, from 8:49 A.M. through 8:57 A.M., the Dietary Manager (DM) said:
-He/She had not scraped off the debris from the outside of the garbage disposal and that in the past, maintenance tried to repair it.
-The Maintenance Director attempted to fix garbage disposal about 2-3 weeks prior to the survey.
-He/She was not sure why they did not label the sugar.
-The bottle with the unidentified liquid on the shelf above the stove was filled with water.
Jun 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · 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 safely provide a two person assist sit-to-stand lift (...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to safely provide a two person assist sit-to-stand lift (is a device that assists a patient to rise from the seated position but does not support the patient's entire body weight, a sling is attached to the lift) transfer by Agency Certified Nursing Assistant (CNA) A, for one sampled resident (Resident #1) that resulted in a major injury of deep tissue laceration (deep cut or tear in the skin or flesh) to his/her right lower leg, out of four sampled residents. The failure has the potential to affect the safety of residents who require assistance with transfers. The facility census was 101 residents.
On 6/14/23, the Administrator was notified of the past noncompliance which occurred on 6/3/23. Facility staff were educated on 6/5/23 related to providing safe mechanical lift transfers with two person assist, to include review of policy for Safe Lifting and Movement of the Resident and updated the Agency CNA's Orientation Information Acknowledgement Sheet to include the use of two person lifts on 6/6/23 and updated the CNA shift-to-shift report sheet as well as the CNA assignment sheet to include the instruction all lift transfers are to be done with two people. The deficiency was corrected as of 6/6/23.
1. Review of Resident #1's admission Face Sheet showed he/she had the following diagnoses:
-Laceration without a foreign body, to his/her right lower leg.
-Dementia.
-Rheumatoid Arthritis
-Long term use of steroids.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/22/23, showed he/she:
-Was severely cognitively impaired and had short term and long term memory problems.
-He/she was able to understand others and make his/her needs known.
-Required limited assistant of one staff member for all cares and transfer.
Review of the facility's undated CNA Report Sheet for resident on the 400 hallway showed:
-The resident required transfer with a gait belt and assist of two staff members.
-Sit-to-Stand and mechanical lifts always required two person assistant.
Review of the resident's Nursing Event Report dated 6/3/23 at 11:42 P.M. showed:
-The resident had a deep irregular shape laceration on right side of his/her lower leg, was about the size of fist.
-The resident's wound had a moderate amount of controlled bleeding.
-The resident had pain rated of 10 out of 10 on the pain scale, indicating excruciating pain.
-The injury happened while transferring the resident.
-Facility staff had applied direct pressure to the wound and applied a bandage, Emergency Medical Services (EMS) were notified.
-Staff notified the resident's physician and family member on 6/4/23 at 12:00 A.M.
-The event note remained open.
Review of the resident's Nursing Note dated 6/4/23 at 12:03 A.M., showed:
-Attached to event note dated 6/3/23 at 11:42 A.M.
-The nurse was notified that assistance was needed due to a serious injury observed by Agency CNA A.
--Upon arrival to the resident's room to assess the resident, it was observed that the resident has a laceration the size a fist on the right outer side of his/her right leg. Blood could be seen on the pants and bed of the resident.
--The wound was not actively bleeding. A pressure bandage was put in place and EMS were called, along with resident's emergency contact and physician.
--When asked what happen, Agency CNA A said the resident was being transferred from his/her wheelchair to the bed. When Agency CNA A removed the resident's pants, he/she observed the wound. Agency CNA A did not see blood on the lift or on the resident's wheelchair.
-Resident was transferred to the hospital by EMS.
Review of the resident's nursing note dated 6/6/23 at 4:54 P.M., showed:
-The resident arrived back at the facility with a nine centimeter (cm) by nine cm dressing to right lower calf area. He/she had a Wound Vacuum Assisted Closure (Wound V.A.C. - negative pressure wound therapy, a type of therapy to help wound healing by decreasing air pressure around the wound with a vacuum pump which pulls fluid and infection from a wound) attached, the dressing had about 25% covered with blood colored (reddish brown) drainage.
Review of the resident's Hospital Discharge summary dated [DATE] showed:
-The resident had a traumatic wound of a large avulsion (is a forcible tearing off of skin, and when any time layers of skin have been torn off, can expose muscles, tendons and tissue) to his/her right lower extremity tissue, with muscle exposure.
-It was unclear of the circumstances regarding the cause of the injury.
-Applied a wound vac to right lower leg.
-Referred to a wound clinic and primary care physician for follow-up.
-No description of the wound was documented in the summary.
Review of the Facility Administrator Summary and Investigation dated 6/6/23 showed:
-He/she had spoken with Agency CNA A who was assigned to the resident.
-On 6/3/23 at approximately 9:15 P.M., the Agency CNA A had arrived to facility for his/her shift, had received report from another staff member and completed walking rounds on assigned residents.
-He/she had transferred the resident to bed with a sit-to-stand lift.
-While Agency CNA A was placing the lifts back sling strap around the resident waist, Resident #1 had complained of pain with movement, but could not communicate where the pain was. The resident repeatedly said he/she felt like he/she was falling. The resident was securely in the sling.
-Agency CNA A provided reassurance throughout the transfer and at no time did Resident #1 scream out suddenly or give any indication that an injury was in progress.
-Agency CNA A and the nurse both looked at the resident's wheelchair and lift and did not see any blood on either, nor was anything sticking out that would have obviously caused the injury.
-Agency CNA A had notified the unit nurse and when the unit nurse saw the resident's injured leg, he/she had requested another nurse to help with resident care.
-Agency CNA A did not ask for assistance with transfer, he/she said No, the sit-to-stands in most places are a one person assist, unlike the Hoyer lift (a mechanical lift) which requires a two person assist.
Review of the resident's care plan revised on 6/13/23 (after the resident injury) showed:
-The resident requires a two person assist for transfers with gait belt.
-He/she was unable to use mechanical lift including the sit to stand.
-Note: The facility were not able to provide documentation of the resident's prior care plan before the incident. The facility electric medical record system does not save past care plans.
Observation on 6/14/23 at 1:10 P.M. of the resident's transfer showed:
-The resident had pink tube covering left side leg rest pegs (to protect from injury to lower left leg) area and had a full leg rest on the right side of the wheelchair.
-Resident said he/she was afraid of falling and reported that several times during the transfer.
-CNA B and Agency CNA C placed the gait belt (a belt, usually made of heavy canvas with a sturdy buckle, used to help residents move)around the resident's waist and then lifted the resident as they pivoted the resident to his/her bed. The resident's right knee bent and had a difficult time flex out flat.
-The resident had an intact dressing to his/her right lower leg with a small amount of brownish drainage noted.
-The resident was not interviewable.
During an interview on 6/14/23 at 9:25 A.M., Restorative Aide (RA) A said:
-He/she was not working the evening of resident incident.
-He/she was in-serviced on proper transfer with a sit-to-stand and all mechanical lifts were to be a two person assist.
-He/she was informed that the resident's injury happen during a transfer.
-Prior to the resident's incident, the resident would be a either a gait belt transferred or two person sit to stand. He/she was not always a two person transfer with the gait belt, it depended on the resident ability to assist during the transfer that day.
During an entrance interview on 6/14/23 at 9:35 A.M., Administrator said:
-The resident's injury occurred during a one person transfer with a sit-to-stand.
-After the final investigation was completed, the root cause was the resident tends to pull his/her right leg backwards while in a wheelchair and during transfers, it was possible he/she had pressed his/her back calf area against the wheelchair leg rest pegs as he/she was being lifted.
-Was noted the resident had a half moon shape wound that was same shape at the leg rest pegs.
-The resident's history of complaints pain were due to a diagnosis of rheumatoid arthritis (an inflammatory disease that may lead to serious joint damage and disability).
-The resident's skin very frail and thin.
During an interview on 6/14/23 at 10:30 A.M. the resident's Family Member said:
-He/she was notified by facility staff on 6/3/23 that the resident was being sent to the hospital due to an injury from a fall.
-The resident required to be sent to a trauma center due to the severity of the wound.
-emergency room physician and EMS said they had never seen anything like the trauma injury to resident's lower right leg.
-He/she had obtained photos of the resident's right leg from hospital. The photos showed an irregular shaped long split of the skin and tissue with exposed yellow fatty tissue, and red-pink muscle tissue. No drainage was noted in the pictures.
-The facility provided the family with a demonstration on how they thought the injury happened. The resident tends to pull his/her right leg backwards and possibly caught his/her pant leg and skin on the wheelchair's leg rest pegs and his/her leg was torn during the lifting of the resident.
-The resident should been transfer lift with a two person assist.
-The resident is being seen by the wound clinic. The hospital could not surgically repair the injury due to the resident's frail skin.
-The resident left hand was contracted and he/she has difficulty holding on to any items and he/she felt the resident could not be able to help support himself/herself during the transfer with a sit-to-stand.
-The resident was fearful of falling due to a history of falling at home.
During an interview on 6/14/23 at 11:50 A.M., CNA B said:
-He/she had worked the day-shift and part of the evening shift on 6/3/23.
-The resident had no skin tears noted at that time.
-The resident required a two person assist with a gait belt for transfers after the incident.
-CNA B had never used a sit-to-stand for the resident.
-He/she would have stopped to see why the resident was in pain before completing the transfer.
-Sit-to-stand transfers should always be a two person assist.
-He/she had been in-served on safe transfers and to always use two people assist with all mechanical lifts after the incident.
-He/she was not aware of the facility sit-to-stand lift having leg straps.
During an interview on 6/14/23 at 1:40 P.M., Director of Rehabilitation Services (DRS) said:
-The resident was being seen by Occupational Therapy (OT) after he/she had returned from the hospital.
-Prior to his/her injury, the resident was a two person sit-to-stand or a two person gait belt transfer.
-The resident has been reevaluated and was now a two person gait belt assist, with a lift pivot and turn.
-He/she and the facility administration staff had established the cause of the resident's injury by recreating how it could have happened during the transfer.
--The resident tended to pull his/her right leg backwards and his/her pant leg and skin could have been caught as the resident was being lifted with the sit to stand.
During an interview on 6/14/23 at 1:40 P.M., Registered Nurse (RN) B and Wound Nurse said:
-The hospital picture of the resident's leg wound made it look bigger then it was.
-The resident was fearful of falling prior to the injury.
-The resident was, most of the time, a two person sit to stand transfer.
-The resident's skin very frail and tears easily.
-The facility staff were provided with in-services on safe transfer and all mechanical lift are a two person transfer after the incident.
-Had updated the agency orientation sheet and CNA shift to shift reports on how to transfer the resident.
-All Hoyer and sit-to-stand transfers require two person assist.
During an interview on 6/14/23 at 2:30 P.M., Director of Nursing (DON) said:
-The finding of the investigation was the Agency CNA A provided a one person sit-to-stand transfer which had caused the injury to the resident's right lower leg.
-The facility administration were continuing to educate care staff on how to safely provide a two person sit-to-stand lift transfer and Hoyer lift transfers.
-The nursing staff and therapy would determine the safest means to transfer a resident and it should be documented in the resident's care plan and CNA care sheets.
-The care plans are updated and the facility was unable to review past care plan interventions if they had been removed.
During an interview on 6/14/23 at 4:11 P.M., Agency CNA A said:
-Another unknown CNA had briefed him/her on care of the residents.
-It was reported to him/her, that the resident was known to yell out in pain often so he/she should not be alarmed.
-During the transfer, the resident was yelling out in pain, but he/she could not express to him/her where the pain was.
-He/she had locked the resident's wheelchair and attached the sling around the resident then secured to the sit-to-stand lift. He/she started to lift the resident and resident voiced he/she was in pain, again he/she could not say where.
-He/she transferred the resident to the bed with the lift.
-He/she was removing the resident's pants and as he/she was lifting the resident's leg, he/she noticed a lot of blood.
-There was no blood trail from the lift to the bed.
-The resident's skin was frail and maybe received a skin tear.
-He/she went to get the nurse, a dressing was applied, and EMS was called.
-When EMS arrived, they said the resident need more care than a regular emergency room visit, he/she needed trauma care due to the type of injury wound.
-Report was given to EMS, it was unknown how the resident was injured during the transfer.
-The wound was pretty bad and was the size of fist, appeared his/her leg may had scrapped on something.
-He/she was briefed on the facility policy for safe transfer with a sit to stand lift and required two person assistance the next day after the incident.
-He/she was informed the next day that the facility had an Agency Orientation Sheet at nursing station to be read signed prior to shift.
-He/she was not made aware on 6/3/23 of Agency Orientation Sheet at nursing station when he/she started his/her shift.
Complaint # MO00219627
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse for two sampled residents (Resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse for two sampled residents (Resident #1 and Resident #2) when both residents were involved in a verbal and physical altercation which resulted in Resident #1 receiving skin tears to his/her left forearm out of four sampled residents. The facility census was 94 residents.
Record review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation originally dated 8/1/01 and revised 12/11/17 showed:
-Abuse would not be tolerated by anyone.
-The patient had the right to be free from abuse.
-Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.
--Willful as used in the definition meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
--Physical abuse included hitting, slapping, pinching and kicking.
-Any patient event that is reported to any partner by patient, family, or other partner or any other person will be considered an allegation of either abuse, neglect, misappropriation of patient property or exploitation if it meets any of the following criteria:
--Any allegation (or) indication of possible willful infliction of injury to include unexplained bruising.
--Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others.
--Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action.
1. Record review of Resident #1's face sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
Record review of Resident #1's Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) showed the resident had a BIMs (brief interview for mental status) of 4, indicating the resident had a severe cognitive impairment.
Record review of Resident #1's undated care plan showed:
-The problem identified with a start date of 10/16/20 and edited 1/9/23:
--He/she had major cognitive deficits as related to history of dementia, alert and oriented to self and familiar people, temporal disorientation and short term memory deficits, long term memory fairly intact, requires max assist with daily decision making.
-The goal with target date 3/26/23 and edit date 1/9/23.
--Will be able to express simple wants/needs to staff daily for 120 days from update/last review and/or
--Will continue to make eye contact when spoken to daily through 120 days from update/last review and/or
--Will continue to respond verbally to others daily through 120 days from update/last review and/or
--Will have needs anticipated by staff daily through 120 days from update/last review and/or
--Will make simple choices daily through 120 days from update/last review and/or
--Will not exhibit complications related to signs and symptoms of delirium through 120 days from update/last review and/or
--Will not express distress related to hallucinations/delusions through 120 days from update/last review and/or
--Will participate in at least one out of room activity daily through 120 days from update/last review and/or
--Will remain oriented to self through 120 days from update/last review.
-The approach dated 10/16/20:
--Allow time to process what has been said and give response.
--Anticipate needs.
--Ask yes/no questions.
--Continue medications and observe for side effects.
--Encourage independence and respect patient's abilities.
--Ensure preferred items are within reach.
--Keep all communication simple.
--Minimize distractions.
--Observe for nonverbal signs and symptoms communication.
--Offer simple choices and assist with decision making as needed.
--Reorient as needed.
--Tell patient who you are and what you will be doing with them.
Record review of Resident #2's face sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait)
-Cognitive Communication Deficit (difficulty with thinking and how someone uses language)
-Unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses)
-Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living)
Record review of Resident #2's Quarterly MDS dated [DATE] showed the resident had a BIMs of 10, indicating the resident had moderate cognitive impairment.
Record review of Resident #2's undated care plan showed:
-The problem identified dated 2/23/22 with edit date 12/6/22:
--Difficulty with adjustment, general attitude, and/or change in relationships.
--Resident was struggling with loss of his/her fiancé and his/her daughter as they moved out of state.
--They used to visit regularly and were very close to one another.
--Staff to provide support as needed.
-The goal with target date 2/22/22 and edit date 12/6/22:
--Will adjust to change in relationships and accept support from staff for 120 days from update/last review and/or
--Will be at ease interacting with others, expressing preferences daily for 120 from update/last review.
-Approach dated 2/23/22:
--Encourage and assist in forging new relationships with others.
--Encourage choices and allow control over daily routine such as meal/clothing selection, participation in activities of choice, etc.
--Encourage to express feelings of sadness, anger, loss.
--Explain changes in schedule, routine as they occur.
--Explain procedures prior to performing.
--Listen to voiced concerns, frustrations and criticisms.
--Observe for change in patient routines and relationships.
--Visit 1:1 to provide support.
-Problem dated 2/22/21 with edit date 12/6/22:
--Resident had some cognitive and communication deficits as related to history of Parkinson's Disease and Dementia, alert and oriented with self and has temporal disorientation, forgetfulness and short term memory deficits, requires moderate assistance with daily decision making.
--Resident can be difficult to understand, expressive aphasia (loss of ability to produce or comprehend language due to brain injury)/difficulty with word finding, poor judgement and safety awareness.
-The goal with target date 2/22/23 edit date 12/6/22:
--Will be able to express simple wants/needs to staff daily for 120 days from update/last review and/or
--Will continue to make eye contact when spoken to daily through 120 days from update/last review and/or
--Will continue to respond verbally to others daily through 120 days from update/last review and/or
--Will have needs anticipated by staff daily through 120 days from update/last review and/or
--Will make simple choices daily through 120 days from update/last review and/or
--Will not exhibit complications related to signs and symptoms of delirium through 120 days from update/last review and/or
--Will not express distress related to hallucinations/delusions through 120 days from update/last review and/or
--Will participate in at least one out of room activity daily through 120 days from update/last review and/or
--Will remain oriented to self through 120 days from update/last review.
-Approach dated 2/22/21:
--Allow time to process what has been said and give response.
--Anticipate needs.
--Ask yes/no questions.
--Continue medications and observe for side effects.
--Encourage independence and respect patient's abilities.
--Ensure preferred items are within reach.
--Keep all communication simple.
--Minimize distractions.
--Observe for nonverbal signs and symptoms communication.
--Offer simple choices and assist with decision making as needed.
--Reorient as needed.
--Tell patient who you are and what you will be doing with them.
Record review of the facility's initial reporting form dated 1/17/23 showed:
-Resident #1 and Resident #2 (who are roommates) had an altercation with each other.
-Both residents were confused.
-Staff observed Resident #2 on the floor and went to assist.
-Staff observed the two residents yelling at each other and Resident #1 holding his/her arm, which was bleeding from a skin tear, and a plastic shoe horn.
-Staff reported that Resident #2 said he/she hit Resident #1 with the shoe horn because Resident #1 called Resident #2 a name.
-Staff reported Resident #1 said he/she would call him/her more than that if they were being hit with a plastic thing.
Record review of Certified Nursing Assistant (CNA) C's written statement dated 1/17/23 showed:
-He/she was called into Resident #1 and Resident #2's room around 3:00 P.M. to assess a resident who had fallen.
-He/she saw Resident #1 and Resident #2 yelling at each other.
-Resident #2 said he/she had struck Resident #1 with a plastic shoe horn because Resident #1 had called him/her a name.
-Resident #1 said they would call him/her something more than that if they were being hit with a plastic thing.
Record review of Licensed Practical Nurse (LPN) A's undated written statement showed:
-He/she was notified by a visitor that a resident was on the floor.
-Resident #2 was on the floor on the right side of Resident #1's bed.
-Resident #1 sat on the side of his/her bed hovering over Resident #2 with a plastic shoe horn raised above his/her head as if he/she was about to hit Resident #2.
-Resident #1 had skin tears to his/her left forearm.
Record review of Resident #1's statement completed by the Social Services Designee (SSD) showed:
-Resident #2 didn't like him/her but they got along.
-He/she was in bed and Resident #2 attacked him/her.
-He/she had to fight Resident #2 off.
-He/she just remembered being hit with a plastic shoe horn and then he/she hitting Resident #2 back.
Record review of Resident #2's undated written statement completed by the SSD showed:
-He/she and Resident #1 were arguing and Resident #1 kept calling him/her a name.
-He/she told Resident #1 he/she was not the name Resident #1 called him/her.
-He/she wheeled over in his/her wheelchair and slapped Resident #1 with his/her shoe horn.
-He/she was so mad that he/she attacked Resident #1.
-He/she went to hit Resident #1 again but the resident tripped him/her.
-He/she never stopped fighting and then staff came in.
Record review of Resident #2's social services note dated 1/18/23 showed the resident was happy Resident #1 was no longer his/her roommate.
Record review of Resident #1's nursing notes dated 1/19/23 showed the resident had several skin tears to his/her left forearm on 1/17/23 after what appeared to be an altercation with Resident #2.
During an interview on 1/26/23 at 9:59 A.M., Resident #1 said:
-He/she had a couple of skirmishes with Resident #2 but nothing too bad.
-Resident #2 wacked him/her with a shoe horn.
-The shoe horn was just plastic.
During an interview on 1/26/23 at 10:05 A.M., Resident #2 said:
-Resident #1 was moved because he/she started a fight with him/her.
-Resident #1 woke up in a terrible mood and called him/her a name.
-He/she told Resident #1 to take it back and Resident #1 called him/her the name again.
-He/she hit Resident #1 with a plastic shoe horn.
-He/she had arguments prior to this with Resident #1.
During an interview on 1/26/23 at 10:35 A.M., CNA C said:
-When he/she went to Resident #1 and Resident #2's room, there were already nursing staff in the room.
-Resident #2 said Resident #1 called him/her a name and Resident #1 said they would call him/her that and more if they were hit with a plastic thing.
-Resident #2 was on Resident #1's side of the room.
-Resident #1 had the shoe horn.
-Resident #2 said Resident #1 hit him/her with the shoe horn.
-Resident #1 had skin tears on his/her arm.
During an interview on 1/26/23 at 1:00 P.M., Registered Nurse (RN) A said:
-He/she went into Resident #1 and Resident #2's room right after the altercation when a hospice (end of life care) nurse said a resident was on the floor.
-Resident #2 was sitting on the floor and Resident #1 was sitting on the bed.
-Resident #1 was holding a shoe horn above his/her head.
-There was blood on Resident #1's arm and on Resident #2's neck and shirt.
-The only injury was a skin tear on Resident #1's arm.
-Resident #2 said Resident #1 called him/her a name.
-Both residents were very poor historians.
-Resident #2's Responsible Party said the resident had told him/her that Resident #1 had said mean things to him/her in the past.
-Resident #2's Responsible Party didn't tell anyone at the facility about it prior to this altercation.
During an interview on 1/26/23 at 1:40 P.M., Certified Medication Technician (CMT) B said:
-Resident #2 said Resident #1 called him/her a name.
-Resident #2 said he/she and Resident #1 had words between them before.
During an interview on 1/26/23 at 1:45 P.M., LPN A said:
-A visitor said someone was on the floor and when he/she and other staff rushed into the room, Resident #1 was sitting on his/her bed and Resident #2 was on the floor on Resident #1's side of the room.
-Resident #1 had two skin tears on his/her left forearm.
-Resident #1 had a plastic device over his/her head like he/she was going to hit Resident #2.
-Both residents had dementia and he/she couldn't understand what had happened.
During an interview on 1/26/23 at 1:55 P.M. SSD said:
-He/she had interviewed Resident #1 and Resident #2.
-Resident #1 had periods of lucidity but was also very confused at times and couldn't speak at times.
-Resident #2 was very lucid when he/she took Resident #2's statement.
-He/she confirmed the information contained in Resident #1 and Resident #2's statements that he/she had written down.
During an interview on 1/26/23 at 2:02 P.M., RN B said:
-A hospice nurse yelled out that there was a patient on the floor.
-Resident #1 was on the bed with a shoe horn in his/her hand.
-Resident #2 was on the floor.
-Both residents had blood on them.
During an interview on 1/26/23 at 2:21 P.M., Resident #2's Responsible Party said:
-Resident #2 said Resident #1 called him/her nasty names and was verbally aggressive.
-Resident #2 said Resident #1 hit him/her.
-Resident #2 said he/she hit Resident #1 back with something and Resident #1 hit him/her again.
-Resident #2 had said Resident #1 was being mean and nasty and calling him/her names before the altercation.
-He/she didn't tell anyone at the facility about this.
-Facility staff would say that Resident #1 and Resident #2 would just grumble at each other.
During an interview on 1/26/23 at 2:34 P.M., the Director of Nursing (DON) and Administrator said Resident #1 cursed at Resident #2 and Resident #2 grabbed a device and hit Resident #1.
During an interview on 1/27/23 at 12:52 P.M., Physician B said:
-Resident #2 has Parkinson's Disease, which could have caused hallucinations.
-Resident #2 has Dementia, which could have been why he/she acted out.
-Resident #2 was diagnosed with a Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system), which could have been why he/she acted out.
MO00212747
Aug 2022
7 deficiencies
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 interview and record review, the facility failed to provide eye drops as ordered for one sampled resident (Resident #74...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide eye drops as ordered for one sampled resident (Resident #74) out of 20 sampled residents. The facility census was 98 residents.
Record review of the facility's medication and treatment orders policy dated as revised July 2016 showed medications shall be administered following written orders.
1. Record review of Resident #74's current face sheet showed:
-The resident was admitted to the facility on [DATE].
-The resident's primary diagnosis was an irregular heartbeat.
-No diagnoses were listed that were related to glaucoma (a condition of increased pressure inside the eye which could lead to blindness) or any other eye disorders.
Record review of the resident's current care plan with multiple dates showed no reference to the resident's eye drops or the resident's vision.
Record review of the resident's Medication Administration Record (MAR) dated July 2022 showed:
-A physician's order dated 7/8/22 for one drop of Timolol Maleate 0.5 % (used to treat high pressure in the eye due to glaucoma or other eye diseases or disorders which can lead to gradual loss of vision) to both eyes at bedtime.
-The resident's eye drops were administered 7/8/22 to 7/27/22.
-On 7/28/22 at 8:00 P.M., it was documented that the eye drops were not administered because they were unavailable and the eye drops were ordered.
-On 7/29/22 at 8:00 P.M., it was documented that the eye drops were not administered because they were unavailable.
-7/31/22 at 8:00 P.M., it was documented that the eye drops were not administered because they were unavailable.
Record review of the resident's August 2022 MAR showed:
-A physician's order dated 7/8/22 for one drop of Timolol Maleate 0.5 % to both eyes at bedtime.
-On 8/1/22 at 8:00 P.M., it was documented that the eye drops were not administered because they were unavailable.
-On 8/2/22 at 8:00 P.M., it was documented that the eye drops were not administered because they were unavailable.
During an interview on 8/3/22 at 9:30 A.M., the resident said he/she had not been getting his/her eye drops.
Record review of the resident's MAR dated August 2022 showed:
-A physician's order dated 7/8/22 for one drop of Timolol Maleate 0.5 % to both eyes at bedtime.
-On 8/3/22 at 8:00 P.M., it was documented that the eye drops were not administered because they were unavailable.
-On 8/4/22 at 8:00 P.M., it was documented that the eye drops were not administered because they were unavailable.
-The resident's eye drops were administered 8/5/22 to 8/7/22.
During an interview on 8/9/22 at 10:03 A.M., Certified Medication Technician (CMT) A said:
-The resident's eye drops were missing at some point.
-Pharmacy comes every night except Sundays and holidays.
-They tried to re-order the resident's eye drops but he/she thought there were some issues with insurance since it was not time for the eye drops to be refilled.
-He/she thinks the eye drops arrived on 8/7/22.
-The resident was in the hospital on 8/8/22.
During an interview on 8/9/22 at 10:33 A.M., Agency Licensed Practical Nurse (LPN) A said:
-If a medication was not there, he/she would first check to see if they had it in the emergency medication kit.
-If they didn't have it, he/she would follow-up with pharmacy and see if they could deliver it stat.
-If that did not work, he/she would see if the doctor could change it to something they had available in the emergency medication kit or change it to something the pharmacy could deliver soon.
During an interview on 8/10/22 at 2:52 P.M., the Director of Nursing (DON) said:
-The CMTs have a thing they can click in the electronic health record system to notify the pharmacy if they were out of a medication/eye drops.
-If the medication/eye drops don't come on the next pharmacy delivery, they should notify the nurse so they can notify the pharmacy.
-If there was a problem getting a medication/eye drops, the nursing staff should have told the Unit Manager or herself/himself so the issue could be investigated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their fall policy which include completing and thoroughly do...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their fall policy which include completing and thoroughly documenting an unwitnessed fall; a fall investigation; and documenting for 72 hours after a fall for one sampled resident (Resident #30) out of 20 sampled residents. The facility census was 98 residents.
Record review of the facility's Falls policy dated March 2018 showed:
-The staff and physician will document in the medical record a history of one or more recent falls.
-The nurse shall assess and document/report the following:
--Vital signs (VS-determination of temperature, pulse rate, rate of breathing, level of blood pressure, and oxygen saturation).
--Recent injury, especially fracture or head injury.
--Musculoskeletal function, observing for change in normal range of motion (ROM - the range on which a joint can move), weight bearing, etc.
--Change in cognition or level of consciousness.
--Neurological status (Neuro Checks-assessing mental status, level of alertness, motor function, pupillary response, cognition, mood and affect and thought content).
--Pain.
--Frequency and number of falls since last physician visit.
--Precipitating factors, details on how fall occurred.
--All current medications, especially those associated with dizziness or lethargy.
--All active diagnoses.
-The staff and practitioner will review each resident's risk factors for falling and document in the medical record.
-The staff will evaluate and document falls as to when and where they happen, and any observations of the events, etc.
-Falls should be identified as witnessed or unwitnessed events.
-The staff and practitioner will begin to try to identify possible causes within 24 hours of the fall.
-The staff and physician will identify pertinent interventions to try to prevent subsequent falls.
-The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma (localized blood filled swelling between the layers of the covering of the brain) have been ruled out or resolved.
1. Record review of Resident #30's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-History of falling.
-Age-related osteoporosis (bones become brittle and fragile from loss of tissue) without current pathological fracture).
-Essential tremor (a nervous system disorder that causes rhythmic shaking not related to Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait).
-Low back pain.
Record review of the resident's undated Care Plan showed he/she:
-Was at risk for falling related to needing assistance with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). Start date 5/13/21.
-Was at risk for decreased strength/mobility. Start Date 1/6/2022.
Record review of the resident's Nurses Notes dated 6/5/2022 at 1:39 P.M., showed:
-Resident was heard yelling for help.
-Staff found him/her on the floor, in a sitting position, with his/her back against the wall, with his/her legs straight.
-Resident said he/she lost balance coming back from bathroom.
-Resident denied hitting his/her head.
-Said his/her back hurt rating the pain a 10/10.
-Four staff assisted the resident up from floor using a Hoyer lift (a mechanical lift) to bed.
-Resident said he/she felt he/she should go to hospital to get checked out.
-Notified the on call Nurse Practitioner (NP) for the Physician.
-Resident notified his/her family his/herself.
-Oxycodone (a narcotic used to relieve moderate to severe pain) 10 milligram (mg) given for pain.
-NOTE: there was no documentation indicating if the fall was witnessed or unwitnessed, the documentation says the staff found the resident on the floor after hearing the resident yelling for help.
Record review of the resident's Nurses Notes dated 6/5/2022 at 3:42 P.M., showed:
-Resident had agreed earlier to have back x-rays done at the facility at the advice of the NP.
-Mobile x-ray had not shown up by this time.
-Resident was saying he/she was in so much pain and would like to go to the emergency room (ER).
-Notified on call NP and called the ambulance service.
Record review of the resident's Nurses Notes dated 6/5/2022 at 9:44 P.M., showed:
-The resident returned from the hospital with a diagnosis of a fracture of the T11 (one of the two lowest vertebrae in your spinal thoracic region).
-An order for Norco 5/325 (pain medication) every 8 hours as needed (PRN) times 12 tabs and a Lidocaine patch (used to help relieve pain. They work as local anesthetics. This means they numb your nerves in a specific area of your body) to back every day remove at hour of sleep (HS).
During an interview on 8/4/22 at 11:31 A.M., the resident said:
-He/she fell about a month ago.
-He/she was standing up and lost his/her balance and fell.
-He/she fractured his/her T11 vertebrae.
Record review of the resident's medical record showed:
-No fall or Incident Report was completed.
-No follow up documentation or charting after the fall and return to facility.
-No documentation of the resident's neuro checks or any pain assessments.
-No documentation of the fall being witnessed or unwitnessed.
During an interview on 8/9/22 at 3:24 P.M., the Director of Nursing (DON) said:
-There should be documentation after a fall that describes what happened and how the resident was found.
-There should be documentation indicating if the fall was witnessed or unwitnessed.
-The nurse should complete nursing notes after falls.
-Since the resident went to hospital, staff probably didn't do the follow up charting.
-Because the resident said he/she didn't hit his/her head, neuro checks didn't need to be done.
During an interview on 8/10/22 at 12:40 P.M., Licensed Practical Nurse (LPN) A said:
-Falls should be charted immediately and throughout each shift for three days if witnessed or unwitnessed.
-If the resident hit his/her head, staff would do neuro checks.
-Documentation should include if the fall was witnessed or unwitnessed, how the fall happened, the environment: floor wet/dry, day or night lights on or off, what resident was wearing: gripper socks, shoes.
-Were there any witnesses and get their statements.
-The resident's Physician, the DON and resident's family should be notified.
-Every shift should chart for three days / 72 hours after a fall.
During an interview on 8/10/22 at 2:51 P.M., the DON and Administrator said:
-The nurse puts in a fall event for all types of falls.
-The nurse starts the incident report.
-The nurse unit manager does a follow up review to be sure the investigation was completed.
-Neuro checks should be done for unwitnessed falls and if the resident hit his/her head.
-Follow up charting should be done for 72 hours after a fall.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an as needed anti-anxiety (used to treat symptoms of anxiety...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an as needed anti-anxiety (used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress) medication order had a limit of 14 days for one sampled resident (Resident #140) out of 20 sampled residents. The facility census was 98 residents.
Record review of the facility's medication orders for stop orders policy dated 1/1/19 showed:
-As needed psychoactive (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) medications were to be automatically stopped after 14 days.
-When the prescriber gave an order for a medication covered by the stop order policy, the nurse could request a specific duration for that order.
-When entering medications covered by the stop order policy on the Medication Administration Record (MAR), the automatic stop date was to be recorded in the appropriate area on the MAR.
1. Record review of Resident #140's current face sheet showed he/she admitted to the facility on [DATE] related to kidney disease and anxiety disorder was one of the resident's diagnoses.
Record review of the resident's July 2022 MAR showed:
-A physician's order dated 7/25/22 for Xanax (an anti-anxiety medication) 0.25 milligrams (mg), one daily as needed and the order was open ended.
-The resident received Xanax 0.25 mg on 7/30/22 at 8:26 P.M.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 8/1/22 showed:
-It was in process.
-There were no other MDS's available for review.
Record review of the resident's August 2022 MAR showed:
-A physician's order dated 7/25/22 for Xanax 0.25 mg, one daily as needed and the order was open ended.
-The resident received Xanax 0.25 mg on 8/2/22 at 7:43 P.M.
-The resident received Xanax 0.25 mg on 8/3/22 at 8:21 P.M.
Record review of the resident's care plan dated 8/3/22 showed the resident had anxiety.
During an interview on 8/8/22 at 3:25 P.M., the facility's consulting Pharmacist said:
-As needed psychoactive medications should have a 14 day limit.
-It was good to see what the resident's pattern of usage was for as needed psychoactive medications for 14 days and then re-assess.
During an interview on 8/9/22 at 10:33 A.M., Agency Licensed Practical Nurse (LPN) A said:
-He/she had been working at the facility as needed for about two months.
-He/she was not aware of the 14 day rule for psychotropic medications that were as needed.
During an interview on 8/10/22 at 2:52 P.M. the Director of Nursing (DON) (who became DON on 7/25/22) said:
-The nurse assigned to the resident enters the resident's admission orders into their system.
-The resident's Xanax 0.25 mg daily as needed order should have a 14-day limit.
-The previous DON used to discontinue those types of orders when they passed 14 days but that had not been happening.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #13's undated face sheet showed:
-The resident was admitted to the facility on [DATE].
-His/her dia...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #13's undated face sheet showed:
-The resident was admitted to the facility on [DATE].
-His/her diagnoses included: coronary artery disease (narrowing of the coronary arteries), high blood pressure, diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) and anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 7/13/22, showed:
-The resident scored a 15 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.
--This showed the resident had no cognitive impairment.
Record review of the resident's medical record showed no Note to Attending Physician/Prescriber Consultant Pharmacist's reviews (Physician's response) for the following months:
-September through December 2021.
-January 2022.
-April 2022.
4. Record review of Resident #82's undated face sheet showed:
-The resident was admitted to the facility on [DATE].
-The resident's diagnoses included diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), heart disease (hardening of the arteries) and anxiety.
Record review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 15, showing no cognitive impairment.
Record review of the resident's medical record showed no Note to Attending Physician/Prescriber Consultant Pharmacist's reviews (Physician's response) for the following months:
-August through December 2021.
-January 2022.
5. During an interview on 8/8/22 12:14 P.M., the Pharmacist said:
-He/she completed the pharmacy reviews each month for all the resident's in the facility.
-He/she would make recommendations as needed.
-He/she would communicate the recommendations on the Consultant Pharmacist's review form for the Physician to respond.
During an interview on 8/8/22 at 1:48 P.M., the Administrator said:
-He/she was unable to find physician responses for Resident #13 for the months of September through December, 2021 and January and April, 2022.
-He/she was unable to find physician responses for Resident #82 for August through December, 2021 and January 2022.
During an interview on 8/10/22 at 2:51 P.M., the DON said:
-The pharmacist did the MRR monthly.
-The pharmacist charted or made a note if there were no recommendations for the month.
-If there was a recommendation the pharmacist wrote a report.
-If there was no recommendation he/she was given a list of all residents they reviewed.
-The physician either agreed or disagreed if there were recommendations.
-The physician marked the review form indicating his/her response and what he/she recommends.
-The pharmacist recommendations were printed off and put in the physician's folder to review on his/her next visit to the facility.
-If the physician was not scheduled then the nurse practitioner would review the recommendations and note his/her response.
-Physicians were typically in the facility one to two times a week.
-One of the physicians received his/her Pharmacist's recommendation forms in fax form.
-The physician should review and responds to pharmacist recommendations within the month.
Based on interview and record review, the facility failed to provide monthly pharmacy medication regimen reviews (MRR) for two sampled residents (Resident #30 and #73) and to provide physician/prescriber responses to MRR for six out of 12 months for two sampled residents (Resident's #13 and #82) out of 20 sampled residents. The census was 98 residents.
Record review of the facility's Consultant Pharmacist Reports Policy, dated 1/1/19, showed:
-The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly.
-The MRR includes evaluation of the resident's response to medication therapy to determine that the resident maintains the highest practical level of functioning and preventing or minimizing adverse consequences related to medication therapy.
-The MRR also involves a thorough review of the resident's record and may include collaboration with other members of the interdisciplinary team, the resident, and the family members or other resident representative.
-MRR also involves reporting of findings with recommendations.
-All findings and recommendations are reported to the Director of Nursing (DON), the attending physician, the medical director and if appropriate the administrator.
-The consultant pharmacist reviews the medication regimen of each resident at least monthly.
-The consultant pharmacist identifies irregularities through a variety of sources including:
--The resident's clinical record, including the Medication Administration Record (MAR).
--Prescribers orders, progress notes, and nurse orders.
--Pharmacy record.
--Other applicable documents.
-Recommendations are acted upon and documented by the facility staff and or the prescriber.
-The prescriber accepts and acts upon suggestions or rejects and provides an explanation for disagreeing.
-If there is potential for serious harm and the attending physician or prescriber does not concur, or refuses to document an explanation for disagreeing, the DON and the consultant pharmacist may contact the medical director.
-The DON or designated licensed nurse address and document recommendations that do not require a physician intervention, such as blood pressure.
-At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and DON.
1. Record review of Resident #30's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Wedge compression fracture (collapsing the bone in the front of the spine) of T11-T12 vertebra (T-thoracic backbone, there are 12), subsequent encounter for fracture (receiving routine care after injury) with routine healing.
-Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas).
-Essential tremor (a nervous system disorder that causes rhythmic shaking not related to
-Parkinson's disease [a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait]).
-Bipolar disorder (a form of mental illness associated with episodes of mood swings ranging from depressive lows to manic highs), unspecified.
-Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), unspecified.
-Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent, severe with psychotic symptoms (mood disturbance is accompanied by either delusions, hallucinations, or both).
-Long term (current) use of aspirin (medication used for mild pain, reducing fevers and inflammations).
-Long term (current) use of antibiotics (medication that destroy or slow down the growth of bacteria).
-Long term (current) use of anticoagulants (medications that help prevent blood clots).
Record review of the resident's undated Care Plan showed:
-Problem: Psychiatric Conditions:
--History of Bipolar disorder.
--Major Depressive disorder with psychotic symptoms.
--Anxiety, prescribed multiple psych medications.
-Start Date 5/13/21.
-Last Reviewed/Revised 7/26/22.
Record review of the resident's medical record showed no Consultant Pharmacist Reviews for the months of September 2021 through January 2022.
During an interview on 8/9/22 at 10:30 A.M., the Administrator said:
-He/she was not able to find any Pharmacist recommendations for September 2021 through January 2022 for the resident.
-The resident was not on the list for having no Pharmacist recommendations for those five months.
2. Record review of Resident #73's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait).
-Psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions and losing touch with reality) with hallucinations (an experience involving the apparent perception of something not present) due to known physiological condition.
-Long term (current) use of aspirin.
-Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) without behavioral disturbance.
-Hallucinations, unspecified.
-Anxiety disorder, unspecified.
-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) unspecified.
Record review of the resident's undated Care Plan showed:
-Psychotropic Drug Use:
--Receives antipsychotic medication related to the diagnosis of Psychotic Disorder.
--Antidepressant daily for Major depressive disorder.
--Antianxiety for Anxiety Disorder
-Start Date 4/12/21.
-Last Reviewed/Revised 08/5/22.
Record review of the resident's medical record showed no Consultant Pharmacist Reviews for the following months:
-September 2021.
-November 2021 through May 2022.
-July 2022.
During an interview on 8/9/22 at 10:30 A.M., the Administrator said:
-He/she was not able to find any Pharmacist recommendations for:
--September 2021.
--November 2021 through May 2022.
--July 2022.
-The resident was not on the list for having no Pharmacist recommendations for those months.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #13's undated face sheet showed he/she was admitted to the facility on [DATE] with the following di...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #13's undated face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception).
-Generalized anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
-Heart failure (inability for heart to pump enough blood).
Record review of the resident's quarterly MDS dated [DATE], showed:
-The resident scored a 14 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.
--This showed the resident had mild to no cognitive impairment.
Record review of the resident's MAR dated July 2022 and August 2022 showed:
-There were no diagnoses listed for the following medications:
--Advair Diskus (fluticasone propion-salmeterol) blister with device; 100-50 microgram (mcg) 1 inhalation twice a day. (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma or ongoing lung disease).
--Alprazolam (Xanax) 1 mg twice daily (used in the treatment of anxiety).
--Cranberry oral capsule, 465 mg once a day (used for reducing the risk of urinary tract infections).
--Furosemide (Lasix) 20 mg once a day (used to reduce extra fluid in the body).
--Metoprolol Tartrate tablet 50 mg once a day (a beta-blocker that affects the heart and circulation (blood flow through arteries and veins).
--Memantine capsule sprinkle, ER 24 hr.: 14 mg once a day (used for the treatment of moderate to severe dementia in people with Alzheimer's disease).
--Omeprazole capsule, delayed release; 40 mg; oral once a day (used to reduce the amount of acid in your stomach).
--Potassium chloride tablet extended release; 10 mEq once a day (used to prevent or treat low potassium levels in the body. Potassium is a mineral that your body needs for proper functioning of the heart, muscles, kidneys, nerves, and digestive system).
3. Record review of Resident #64's undated face sheet showed:
-The resident was admitted to the facility on [DATE].
-The resident's diagnoses included muscle weakness, history of falls, depression and history of a stroke.
Record review of the resident's significant change MDS dated [DATE], showed:
-The resident scored a 13 on the BIMS.
--This showed that the resident had little to no cognitive impairment.
Record review of the resident's MAR dated July 2022 and August showed:
-There were no diagnoses listed for the following medications:
--Baclofen tablet 5 mg (used to treat pain and certain types of spasticity (muscle stiffness and tightness).
--Calcium carbonate 500 mg (used to prevent or treat osteoporosis).
--Cholectalciferol (vitamin D3) capsule; 50 mcg (2,000 unit) once a day (used to treat vitamin D deficiency).
--Macrobid (nitrofurantoin monohyd/m-cryst) capsule; 100 mg (an antibiotic used treat bladder infections).
--Miralax (polyethylene glycol 3350) [OTC]; powder; 17 gram/dose oral (PRN) (used to treat constipation).
--Multivit-min-iron fum-folic ac tablet; 7.5 mg iron-400 mcg once a day (used to fill nutritional gaps and make sure people get their daily allowance of underconsumed nutrients like vitamins A, C, D, E and K, calcium, magnesium, dietary fiber, choline and potassium).
--Osteo Bi-Flex (glucosamine-chondroitin) tablet; 250-200 mg 2 tablets once a day (used to treat osteoarthritis).
--Simvastatin tablet; 20 mg 1 talet at bedtime (used to to lower the amount of cholesterol and other harmful substances in the blood).
--Spironolactone table; 50, mg 1 tablet once a day (used to promote sodium excretion and is used in the treatment of certain types of edema and hypertension).
--Zoloft (sertraline) tablet; 50 mg once a day (used to treatdepression).
--Fleet Enema (sodium phosphates) [OTC]; 19-7 gram/118mL (PRN) (used to treat constipation).
4. Record review of Resident #30's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Wedge compression fracture (collapsing the bone in the front of the spine) of T11-T12 vertebra (T-thoracic backbone, there are 12), subsequent encounter for fracture (receiving routine care after injury) with routine healing.
-Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas).
-Essential tremor (a nervous system disorder that causes rhythmic shaking not related to
-Parkinson's disease [a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait]).
-Bipolar disorder (a form of mental illness associated with episodes of mood swings ranging from depressive lows to manic highs), unspecified.
-Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), unspecified.
-Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent, severe with psychotic symptoms (mood disturbance is accompanied by either delusions, hallucinations, or both).
-Long term (current) use of aspirin (medication used for mild pain, reducing fevers and inflammations).
-Long term (current) use of antibiotics (medication that destroy or slow down the growth of bacteria).
-Long term (current) use of anticoagulants (medications that help prevent blood clots).
Record review of the resident's Care Plan dated as last reviewed/revised 7/26/2022 showed:
-Problem: Psychiatric Conditions:
--History of Bipolar disorder.
--Major Depressive disorder with psychotic symptoms.
--Anxiety, prescribed multiple psych medications.
--Insomnia (difficulty falling or staying asleep).
-At risk for decreased strength/mobility.
-At risk for falling related to needing assistance with Activities of Daily Living (ADL)'s.
-At risk for pressure ulcers related to needing assistance with ADL's.
Record review of the resident's Physician Order Summary (POS) and MAR dated August 2022 showed no diagnoses for the following medications:
-Acetaminophen tablet; 500 mg tablet; give 2 tablets PO every 8 Hours as needed (PRN) (used for mild pain).
-Actonel 35mg PO in morning (used for prevention and treatment of osteoporosis).
-Artificial tears 1.4%; 1 drop both eyes three times a day (TID) (used for dry eyes).
-Ascorbic acid (vitamin C) 500mg tablet PO daily (used as a vitamin supplement).
-Aspirin 81mg chewable tablet PO daily (used to prevent heart attack or stroke).
-Benzonatate capsule; 100 mg PO every 4 Hours PRN (used for treating coughs).
-Bisacodyl delayed release (DR) 10mg tablet PO daily (used to treat constipation).
-Buspirone 5mg PO every 8 hours (used to treat anxiety).
-Calcium Carbonate -vitamin D3; 600mg-10 micrograms (mcg) 1 tablet PO twice a day (BID) (used as a supplement).
-Cyclobenzaprine 10mg tablet PO BID (used to help relax certain muscles in body).
-Depakote ER (extended release) 500mg PO every 24 hours (used for behaviors).
-Diclofenac sodium gel; 1 %; amount: 2 gram (gr); topical four times a day PRN (used as a pain reliever and anti-inflammatory agent).
-Docusate Sodium 100mg capsule; give 2 capsules PO BID (used as a laxative).
-Gabapentin 100mg PO TID (used for nerve pain).
-Geri-Lanta (alum-mag hydroxide-simeth) suspension; 400-400-40 mg/5 mL; amount: 15 ml; PO Every 12 Hours - PRN (used for heartburn and indigestion).
-Geri-Tussin (guaifenesin) liquid; 100 mg/5 mL; amount: 30 ml; PO every 8 hrs.-PRN (used for treating coughs).
-Geri-Tussin DM (dextromethorphan-guaifenesin) liquid; 10-100 mg/5 mL; amount: 5 ml; PO Every 4 Hours (used for treating coughs).
-Levothyroxine 50 mcg 1 tablet PO every morning (used to treat underactive thyroid gland).
-Methenamine Hippurate 1 tablet PO take with Vitamin C TID (used to prevent urinary tract infections due to bacteria).
-Milk of Magnesia (magnesium hydroxide) suspension; 400 mg/5 mL; amount: 30 ml; PO PRN (used for occasional constipation).
-Miralax powder 17gms PO daily (used to treat occasional constipation).
-Multiple Vitamin with minerals 1 tablet PO daily (used as a vitamin supplement).
-Omeprazole DR 40mg 1 capsule PO daily (used for heartburn and indigestion).
-Oxybutynin Chloride 10mg ER tablet PO BID (used to treat symptoms of an overactive bladder)
-Pataday Once Daily Relief (Olopatadine) 0.2% 1 drop in both eyes daily (used to treat itching eyes).
-Primidone 50mg tablet take 3 tabs PO in morning (used to control seizures in treatment of epilepsy).
-Primidone 50mg tablet take 4 tabs PO at bedtime (used to control seizures in treatment of epilepsy).
-Refresh Liquigel eye drops 1%; 1 drop each eye BID (used for dry eyes).
-Risperidone 0.5mg tablet PO at bedtime (used to treat bipolar disorder).
-Simvastatin 20mg tablet PO at bedtime (used to treat high cholesterol).
-Ventolin HFA (Albuterol Sulfate) inhaler; 90mcg/actuation; 2 puff inhalation every 6 hours PRN (used to treat or prevent bronchospasm [airway muscles tighten]).
-Vitamin D3 25mcg tablet; 2 tablets PO daily (used as a vitamin supplement).
-Xarelto 10mg tablet PO daily (used to reduce risk of stroke and blood clots).
5. Record review of Resident #73's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait).
-Psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions and losing touch with reality) with hallucinations (an experience involving the apparent perception of something not present) due to known physiological condition.
-Long term (current) use of aspirin.
-Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) without behavioral disturbance.
-Hallucinations (an experience involving the apparent perception of something not present).
-Anxiety disorder (anticipation of imp ending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) unspecified.
-Obstructive sleep apnea (breathing interrupted during sleep for longer than 10 seconds at least five times per hour throughout sleep period).
-Chronic pain syndrome (persistent pain that lasts weeks to years).
Record review of the resident's Care Plan dated last reviewed 8/5/2022 showed:
-Psychotropic Drug Use:
--Receives antipsychotic medication related to the diagnosis of Psychotic Disorder
--Antidepressant daily for Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
--Antianxiety for Anxiety Disorder.
Record review of the resident's POS and MAR dated August 2022 showed no diagnoses for the following medications:
-Aspirin 81mg chewable tablet PO daily (used to prevent heart attack or stroke).
-ClearLax powder 17gr PO every morning (used to treat constipation).
-Cyclobenzaprine tablet; 5 mg; PO every 8 Hours PRN (used to help relax certain muscles in body).
-Hydrocodone-Acetaminophen 5-325 mg tablet; give 1 tablet; PO every 4 Hours - PRN (used for moderate to severe pain).
-ICaps AREDS2 (vitamin C, E, zinc, Ox-[NAME]-Lut-Zeax) capsule, 250mg-200 Unit-12.5mg-1mg; give 1 capsule PO daily (eye supplement)
-Namenda 10mg tablet PO BID (used to treat moderate to severe dementia related to Alzheimer's disease).
-Nourianz 20mg tablet PO daily (used to for Parkinson's disease with levodopa and carbidopa)
-Nuplazid (Pimavanserin) 34mg capsule PO at bedtime (used to treat hallucinations and delusions with Parkinson's disease psychosis)
-Omega 3 Fatty Acids-Fish Oil 300-1,000 mg capsule PO daily (use to reduce pain and swelling and prevent blood clots).
-Potassium Chloride ER tablet 10milliequivilent (mEq) PO daily (used to treat or prevent low amounts of potassium in the blood).
-Senna-S 8.6-0mg tablet PO daily (used to relieve occasional constipation).
-Tramadol 50mg tablet; take 2 tablets PO every 6 hours (used for moderate to moderately severe pain).
-Vitamin D3 tablet; 1,000 unit; take 2 tablets PO daily (used as a vitamin supplement).
6. Record review of Resident #190's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Displaced comminuted fracture of shaft of right femur.
-Hypertensive heart disease with heart failure
-Chronic diastolic (congestive) heart failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should).
-Iron deficiency anemia (a condition of lack of enough healthy red blood cells to carry adequate oxygen to the body's tissues).
-Paroxysmal atrial fibrillation (episodes of AFib that occur occasionally and usually stop spontaneously; [AFib the atria [top chambers of heart] quiver and beat irregularly]).
-Hypotension (low blood pressure).
-Angina pectoris (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart).
-Hyperlipidemia (high concentration of fats or lipids in the blood).
-Hypothyroidism (under active thyroid - the thyroid gland doesn't produce enough thyroid hormone - can disrupt such things as heart rate, body temperature, and all aspects of metabolism).
-Benign prostatic hyperplasia [BPH-enlargement of the prostate gland blocks the urethra (the tube that carries urine from the bladder out of the body) causing problems with urinating) without lower urinary tract symptoms.
-Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
Record review of the resident's POS and MAR dated August 2022 showed no diagnoses for the following medications:
-Clotrimazole 1% cream topical BID PRN (used to treat skin infections caused by a fungus [yeast]).
-Escitalopram Oxalate (Lexapro) 20mg PO daily (used to treat depression and anxiety).
-Ferrous Sulfate 325mg PO daily with breakfast (used to treat and prevent iron deficiency anemia).
-Fish Oil (Omega 3 Fatty Acids-fish oil) 340-1,000 mg capsule PO daily (use to reduce pain and swelling and prevent blood clots).
-Furosemide (Lasix) 40mg tablet PO daily (used high blood pressure and edema).
-Gabapentin 300mg capsule PO TID (used for nerve pain).
-Loperamide (Imodium) 2mg capsule PO 4 times a day PRN (used to treat diarrhea).
-Midodrine 5mg PO daily (used to treat low blood pressure).
-Propafenone 225mg PO BID (used to prevent AFib).
-Senna-S 8.6-0mg tablet PO daily (used to relieve occasional constipation).
-Tamsulosin 0.4mg PO BID (used to help reduce enlarged prostate gland).
-Tramadol 50mg PO every 4 hours PRN (used for moderate to moderately severe pain).
-Xarelto 10mg PO daily (used to reduce risk of stroke and blood clots).
-Zolpidem 10mg PO at bedtime (used to treat insomnia).
7. During an interview on 8/8/22 at 3:25 P.M., the facility's consulting Pharmacist said:
-There should be diagnoses for all medications.
-He/she sent regular reminders to nursing staff about including diagnoses in the medication orders.
-Usually the physician included the diagnoses for medication orders.
-Whoever put the medication orders in the computer did not include the diagnoses.
During an interview on 8/10/22 at 2:52 P.M. the Director of Nursing (DON) said:
-The nurse assigned to the resident upon the resident's admission was the one responsible for putting the physician's orders in with the diagnosis.
-All medications should have diagnosis for use on their MAR.
Based on interview and record review, the facility failed to ensure each resident's drug regimen had diagnoses or adequate indications for each medication for five sampled residents (Residents #140, #64, #13, #30 and #73) and one supplemental resident (Resident #190) out of five sampled residents and one supplemental resident sampled for unnecessary medications out of 20 sampled residents. The facility census was 98 residents.
Record review of the facility's medication and treatment orders policy dated as revised July 2016 showed orders for medications must include the clinical condition or symptoms for which the medication is prescribed.
1. Record review of Resident #140's current face sheet showed he/she was admitted to the facility on [DATE] related to kidney disease and his/her diagnoses included diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), anxiety disorder (psychiatric disorders that involve extreme fear, worry and nervousness) and depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 8/1/22 showed it was in process.
Record review of the resident's August 2022 Medication Administration Record (MAR) showed:
-There were no diagnoses for the following physician ordered medications:
--Coreg 6.25 milligrams (mg) twice a day (used to treat high blood pressure and heart failure).
--Eliquis 2.5 mg twice a day (used to treat and prevent blood clots and to prevent strokes).
--Glipizide 5 mg twice a day (helps control blood sugar levels).
--Januvia 50 mg once a day (helps lower blood sugar levels).
--Lumigan drops 0.01% one drop once a day to left eye (used to treat glaucoma).
--Ondansetron 4 mg every six hours as needed (used for nausea).
--Preparation H every six hours as needed (used to treat hemorrhoids).
--Timolol Maleate 0.5% one drop at bedtime to each eye (used to treat glaucoma).
--Xanax 0.25 mg once a day (used to treat anxiety and panic disorders).
Record review of the resident's care plan dated 7/26/22 and 8/3/22 showed:
-The resident had a diagnosis of depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life) and anxiety.
-The resident received an anticoagulant medication (medication used to slow down the blood clotting process).
-The resident received medication for diabetes and pain.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #64's undated face sheet showed:
-He/she was admitted to the facility on [DATE].
-His/her diagnoses...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #64's undated face sheet showed:
-He/she was admitted to the facility on [DATE].
-His/her diagnoses included muscle weakness, history of falls, depression and history of a stroke.
Record review of the resident's nurse progress notes from April 2022 showed no evidence of a TST being given to the resident upon admission.
During an interview on 8/10/22 at 2:22 P.M., the Administrator said:
-The TB results for the resident could not be found.
-He/she put in an order to have it done as soon as possible.
3. During an interview on 8/10/22 at 2:40 P.M., Licensed Practical Nurse (LPN) A said:
-All new residents' needed a TB first step test done at the time of admission.
-The charge nurse was the one who should administer it.
-It should be read in 48 to 72 hours after given.
During an interview on 8/10/22 at 2:56 P.M., the Director of Nursing (DON) said:
-TB testing should be completed upon admission of a resident.
-First do the first step of the TST then read it two days later.
-Complete the second step in seven days and read it two days after administering.
-Long term care residents had an annual TB screening once the initial skin test was completed.
-The admitting nurse was responsible for administering the TST injections.
-Once administered and recorded in the electronic health record (EHR) then a reminder pops up on the screen to read the results two days later.
-Currently there was no one assigned to the roll of tracking resident TB testing.
-The Infection Preventionist would be put in charge of it.
During an interview on 8/10/22 at 2:56 P.M., the Administrator said:
-He/she started a facility wide audit to see what residents had not gotten a TST upon admission.
-Residents #64 and #191 received the first step TST today.
Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for one sampled resident (Resident #64) and one supplemental resident (Resident #191) out of 20 sampled residents and 11 supplemental residents. The census was 98 residents.
Record review of the facility's Early Identification and Management of Persons Suspected of Having Tuberculosis Disease Policy, dated February 2022, showed:
-Screening and Surveillance of Residents:
--A physician's order for a Two-Step Tuberculin Skin Test (TST) should be requested upon admission.
--Each resident will receive a two-step TST upon admission unless they have a history of a positive TST or have a documented negative TST within the last 12 months.
--If a resident has a documented negative TST within the last 12 months, a one-step TST will only be required.
--The TST results should be read and documented by a Licensed Nurse 48-72 hours after the TST was administered.
--If the test is not read within 72 hours the test should be repeated.
--If the resident had a history of a positive TST, a chest x-ray will be done to rule out TB disease, unless the resident had documented evidence of a negative chest x-ray within the last six months.
--Long term residents will receive a TB symptomology screening at least annually.
1. Record review of Resident #191's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Fracture left femur neck [(broken hip) the part of the leg bone just below the ball and socket joint].
-Congestive Heart Failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should).
-Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing).
Record review of the resident's medical records since his/her admission showed no evidence of a TST being given to the resident upon admission.
During an interview on 8/10/22 at 2:22 P.M., the Administrator said:
-He/She could not find any record of the resident receiving the first or second TST.
-He/She just now put in an order to do as soon as possible.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the kitchen, Dry Storage room, and walk-in refri...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the kitchen, Dry Storage room, and walk-in refrigerator and walk-in freezer floors clean and free from pests; to safeguard against foreign material possibly getting into food and/or beverages; to keep trash and garbage receptacles lidded; to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; and to separate damaged foodstuff. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 98 residents with a licensed capacity for 120 residents.
1. Observations during the initial kitchen inspection on 8/3/22 between 9:03 A.M. and 11:18 A.M. showed:
-In the food tray pick-up room the ice machine had two large rusted areas approximately 3 square inches on both bottom corners of the plastic lid's metal frame.
-The Dry Storage room floor was very sticky and there were numerous small black plastic containers, a breakfast syrup pod, two club cracker packet wrappers, two ketchup packets, a large empty plastic zip-lock bag, and various scraps of paper and plastic on the floor proper and under the storage racks.
-An unopened 128 ounce (oz.) plastic jar of sweet pickle relish was on the floor in front of a can dispenser rack in the dry storage room.
-There was a 112 oz. can of peach pie filling that was dented on the side on the large can dispenser rack.
-On the large can dispenser rack itself there was an unknown thick dark yellow partially dried substance approximately 2 inches wide dripping from the rack of 112 oz. cans of banana pudding that was 6th from bottom, down through and onto each successive rack to the bottom, and an abundance of gnats on the substance itself.
-Many gnats were also on other storage shelves and flying throughout the room.
-The walk-in freezer had 2 large 16 oz. tubs of whipped topping, plastic cup lids, and numerous scraps of paper and plastic under the racks, along with one open bag of frozen potatoes sitting on a box of frozen potato bags on a lower shelf.
-There were two large uncovered metal trays on the upper racks of a large roller transport cart that each had numerous small plates with 2 cookies each on them.
-There were several various sized scraps of food and crumbs under the storage racks in the walk-in refrigerator.
-A brown handled spatula on the rack over a food preparation table had a yellowed plastic blade with large chips around the edges.
-The kitchen janitor's closet had a multitude of gnats inside.
-A tall thin grey trash can by the sink next to the janitor's closet was missing its double self-closing lids and trash protruded over the top.
-A large round garbage can next to the dishwashing area was 1/3 full of trash, garbage and food scraps with its lid sitting on the floor next to it.
-A tall thin grey trash can by the silver K-Class fire extinguisher was missing its double self-closing lids and trash protruded over top.
-The blue, white, brown, green, yellow, and red cutting boards under a food preparation table were all heavily scored to the point of plastic bits flaking off.
-In the food tray pick-up room there were numerous grey plate warmer lids that had their edges chipped to the point of plastic bits flaking off.
-The baked chicken for lunch was taken out of the oven and placed on the steam table with no temperatures taken to ensure they were thoroughly cooked.
Observations on 8/3/22 at 10:55 A.M. showed a transport cart with an uncovered tray of cookies and an uncovered tray of numerous small bowls with grapes in them being taken from the kitchen through the main dining room and down a hall through double doors to the 400 Hall.
Observations during the follow-up kitchen inspection 8/4/22 at 9:35 A.M. showed:
-On the large can dispenser rack in the Dry Storage room there was an unknown thick dark yellow partially dried substance approximately 2 inches wide dripping from the rack of 112 oz. cans of banana pudding that was 6th from bottom, down through and onto each successive rack to the bottom, and an abundance of gnats on the substance itself.
-The walk-in freezer had 2 large 16 oz. tubs of whipped topping, plastic cup lids, and numerous scraps of paper and plastic under the storage racks.
-A brown handled spatula on the rack over a food preparation table had a white plastic blade with large chips around the edges.
-The tall thin grey trash can by sink next to the janitor's closet and the tall thin grey trash can by silver the K-Class fire extinguisher were both missing their double self-closing lids.
-The blue, white, brown, green, yellow, and red cutting boards under food a preparation table were all heavily scored to the point of plastic bits flaking off.
-In the food tray pick-up room there were numerous grey plate warmer lids that had their edges chipped to the point of plastic bits flaking off.
Observations during the follow-up kitchen inspection in the Dry Storage room [ROOM NUMBER]/5/22 at 9:39 A.M. showed:
-On the large can dispenser rack there was an unknown thick dark yellow partially dried substance approximately 2 inches wide dripping from the rack of 112 oz. cans of banana pudding that was 6th from bottom, down through and onto each successive rack to the bottom.
-There was an upside down box of pancake maple syrup pods on the floor that was leaking syrup from one corner.
-The floor was sticky.
-There were several gnats flying about.
During an interview on 8/9/22 at 10:01 A.M., the Certified Dietary Manager said:
-The cooks are responsible for cleaning the Dry Storage room, walk-in refrigerator, and walk-in freezer floors twice a week after deliveries.
-Staff will notify him/her when food preparation items are damaged or need replaced; there are usually extras on hand.
-Foods should have their temperatures taken as they come out of the oven or off the stove, and also when they are on the steam table before serving them.
-He/She would expect foods being carted to the resident halls to be covered.
-Food should be free from any contaminants.
-He/She was aware of the missing trash can lids; they just broke from overuse.
-He/She just noticed the gnat problem a few days ago.
-The exterminator treats the kitchen once a month and as needed.
During an interview on 8/9/22 at 11:08 A.M the Maintenance Director said:
-The exterminator comes to the facility every month and as needed.
-The kitchen perimeter is sprayed.
-He/she did not know if the Dry Storage room is sprayed because of all the food in there.
During an interview on 8/9/22 at 11:45 A.M., the Administrator said:
-They had a routine pest control program for the facility.
-He/she did not know how long the gnats were a problem in the kitchen.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed:
-Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
-Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.
Nov 2019
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure coordination of care between the facility and ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure coordination of care between the facility and the dialysis (a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure) center was maintained to ensure the continuum of care for one sampled resident (Resident #304) out of 21 sampled residents. The facility census was 104 residents.
Record review of the facility's undated Dialysis Communication Worksheet showed:
-Pre-dialysis report completed by the facility nurse:
--An assessment of the resident including falls, edema (swelling), dialysis access site, skin, any recent changes, appetite, mental status and fluid restrictions.
-The nurse was to attach the current physician's orders and any laboratory services.
-Post-dialysis completed by the dialysis clinic:
-Dialysis start and stop times, a wet weight and a dry weight, laboratory services, any dressings placed on the dialysis access site, meals, any medications that were given, and any complications related to dialysis treatment.
1. Record review of Resident #304's Face Sheet showed he/she was admitted to the facility on [DATE] for Medicare Part A skilled services with a diagnosis of End Stage Renal Disease (ESRD-kidney failure).
Record review of the resident's Physician's Orders Report (POR) dated October 2019 showed a physician's order for dialysis on Tuesday, Thursday, and Saturday.
Record review of the resident's Care Plan Conference Summary which included the resident's baseline care plan dated 10/11/19 showed the resident received dialysis on Tuesday, Thursday, and Saturday.
Record review of the resident's interdisciplinary progress notes dated 10/11/19-11/4/19 showed no documentation related to dialysis communication forms.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/17/19 showed he/she received dialysis services.
Observation on 11/1/19 at 2:05 P.M., showed the resident had an arteriovenous (AV) graft (a strong artificial tube inserted by a surgeon underneath the skin of your forearm, upper arm or thigh used for dialysis) in his/her inside, upper, left arm.
Record review of the resident's Medical Record electronic medical record on 11/4/19 showed no documentation related to dialysis communication forms.
During an interview on 11/5/19 at 9:15 A.M., the Director of Nursing (DON) said the Dialysis Communication Sheets were not being completed for the resident.
During an interview on 11/5/19 at 9:52 A.M., Licensed Practical Nurse (LPN) F said:
-A Dialysis Communication Worksheet in the electronic medical record was completed by the charge nurse and was sent with the resident to dialysis.
-He/she would assess the resident to show the current condition of the resident and include this on the form.
-Pre-dialysis (wet) weights and after dialysis (dry) weights were completed by the dialysis clinic and documented on the form.
-When the resident returns from dialysis, he/she would review the form, look for any concerns, and process any new physician's orders that were on the form and
-The form had not been completed for the resident since he/she was admitted .
During an interview on 11/5/19 at 10:03 A.M., the Assistant Director of Nursing (ADON) said:
-The nurses were responsible for assessing the resident prior to dialysis, obtaining a wet weight of the resident and writing the residents medications on the Dialysis Communication Worksheet.
-The nurses would send the form with the resident to dialysis.
-The dialysis clinic would complete the form including a dry weight and an assessment of the resident and
-The nurse was responsible for processing any information from the form when the resident returned from dialysis.
During an interview on 11/5/19 at 1:09 P.M., DON said:
-The nurses were responsible for completing the Dialysis Communication Sheets for the residents including obtaining a wet weight and assessing the resident prior to dialysis.
-The form was sent to dialysis with the resident.
-The dialysis clinic was responsible for filling out a separate form including a dry weight of the resident, their vital signs, and any laboratory testing that was completed at the dialysis clinic and
-The resident would bring the form from dialysis to the charge nurse at the facility so the nurse could review it.
A policy was requested but not received by the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure narcotic counts were done every shift with the accompanying signatures from an on-coming and off-going staff member to verify the co...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure narcotic counts were done every shift with the accompanying signatures from an on-coming and off-going staff member to verify the correct narcotic count. The facility census was 104 residents.
Record review of an un-named policy, updated on 5/1/15 showed:
-The off going nurse (or designee) will be responsible for the verification of the narcotic count sheet corresponding to the medication contained within the locked narcotic box.
-Together, both nurses (or a designee) will verify resident, medication, and count are correct for each individual medication contained within the locked narcotic box.
-Together, both nurses (or a designee) will verify that the physical card count matches the card count log; and
-At the completion of the count process both the off-going and the receiving nurse (or designee) will confirm the accurate narcotic count by signing on the Verification of Narcotics Count Sheet.
1. Record review of the Certified Medication Technician (CMT) Narcotic Inventory Sheet showed the CMT cart had:
-For September 2019:
--25 missing signatures out of 120 opportunities, resulting in a 21 percent (%) missing rate; and
-For October 2019:
--75 missing signatures out of 124 opportunities, resulting in a 60% missing rate.
During an interview on 11/4/19 at 10:30 A.M. CMT D said, one on-coming staff and one off-going CMT/nurse would:
-Conduct a narcotic count each shift to ensure the correct narcotic count; and
-After the narcotic count was completed and correct, they would sign the Narcotic Inventory Sheet.
During an interview on 11/5/19 at 10:23 A.M. Licensed Practical Nurse (LPN) D said:
-Narcotics count occurred at the change of every shift and
-One on-coming staff and one off-going staff signed the Narcotic Inventory Sheet to verify accuracy.
During an interview on 11/5/19 at 10:30 A.M. LPN E said:
-He/she expected the staff to conduct narcotic counts every shift; and
-He/she expected the staff to sign the Narcotic Inventory Sheet as proof of the count.
During an interview on 11/5/19 at 11:00 A.M. the Director of Nursing (DON) said, he/she expected:
-Staff performed narcotic counts every shift; and
-Staff signed the Narcotic Inventory Sheet when the narcotic count was completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacy consultant identified irregularities in the res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacy consultant identified irregularities in the resident's medication order for a Pro Re Nata (PRN-as needed) psychotropic medication (medications that affect mental function, behavior, or experience) to ensure the order was limited to 14 days and there was a specified duration for use when extending duration of a PRN anti-anxiety medication (drug used to reduce intense and persistent worry, fear and anxiety) beyond the initial 14 days for one sampled resident (Resident #45) out of 21 sampled residents. The facility census was 104 residents.
Record review of the facility Consultant Pharmacist Reports Medication Regimen Review policy dated June 2016 showed:
-The consultant pharmacist reviews the medication of each resident at least monthly.
-In performing medication regimen reviews, the consultant incorporates federally mandated standards of care, in addition to other applicable professional standards.
-The duration of the therapy (medication order) is considered and is appropriate for the resident.
-Resident-specific irregularities and/or clinically significant risk resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nursing (DON), and/or prescriber as appropriate.
1. Record review of Resident #45's Face Sheet showed:
-He/she was admitted to the facility on [DATE].
-He/she had a diagnosis of generalized anxiety disorder (excessive, exaggerated anxiety and worry about everyday life events with no obvious reasons for worry).
Record review of the resident's Consultant Pharmacist Medication Regimen Review Communication forms dated 2/19/19 through 9/17/19 showed:
-The facility consultant pharmacist reviewed the resident's medication regimen monthly on 2/19/19, 3/19/19, 4/16/19, 5/21/19, 6/21/19, 7/22/19, 8/20/19 and 9/17/19.
-The facility consultant pharmacist sent communication to the facility psychiatrist on 3/19/19 and 7/22/19.
Record review of the resident's consultant Pharmacist Medication Regimen Review Communication dated 7/22/19 showed:
-The resident received escitalopram (antidepressant medication) 10 milligrams (mg) each day (q day) and mirtazapine (antidepressant medication) for depression 15 mg each bedtime (q hs) for depression.
-Please assess if the resident would benefit from a gradual dose reduction of his/her antidepressant medication.
-No mention of the resident's PRN alprazolam antianxiety medication that was ordered on 12/16/18.
Record review of the resident's October 2019 Physician's Orders Sheet (POS) showed:
-An order dated 12/16/18 for alprazolam (antianxiety medication) one (1) mg every six hours as needed, without a duration time frame or stop date.
-General anxiolytic (antianxiety) PRN every six hours non-pharmacological interventions including redirection, massage, and music, dated 12/31/18.
Record review of the resident's October 2019 and November 2019 Medication Administration Record (MAR) showed he/she had last received his/her Xanax 1 mg PRN on 10/21/19.
During an interview on 11/5/19 at 10:09 A.M. Licensed Practical Nurse (LPN) G said:
-The resident had a physician's order for alprazolam 1 mg every six hours.
-The resident would ask for his/her alprazolam when he/she needed it before his/her anxiety got out of hand and he/she had not had alprazolam in November 2019.
-The resident's alprazolam PRN order was dated 12/16/18.
-PRN psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) were usually only written for 90 days for some psychoactive medications.
-He/she had known of a 14 day limit for the original order for PRN psychotropic medications and that if the order was renewed there still needed to be a time frame for the order.
-He/she had not thought about the resident having a time limit for his/her PRN alprazolam.
-He/she now saw that there was no time frame for the resident's PRN alprazolam.
-Had he/she noticed the date of 12/16/18 for the resident's PRN alprazolam, he/he might have called the resident's physician or let the Director of Nursing (DON) know.
During an interview on 11/5/19 at 1:09 P.M. the DON said:
-PRN antianxiety medications have to be looked at and evaluated by the physician every 15 days.
-The residents PRN antianxiety medication not having a duration limit should have been caught by the consultant pharmacist during completion of the resident's monthly drug regimen reviews.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Pro Re Nata (PRN-as needed) psychotropic medica...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Pro Re Nata (PRN-as needed) psychotropic medications (medications that affect mental function, behavior, or experience) orders were limited to 14 days and there was clinical indication and a specified duration for use when extending antianxiety medications (drugs used to reduce intense and persistent worry, fear and anxiety) beyond the initial 14 day period for one sampled resident (Resident #45), out of 21 sampled residents. The facility census was 104 residents.
Record review of the facility Medication Monitoring and Management policy dated 1/1/19 showed:
-In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use.
-The resident and medication regimen is evaluated when an order for PRN psychotropic medications do not meet the PRN requirements for psychotropic medications.
1. Record review of Resident #45's Face Sheet showed:
-He/she was admitted to the facility on [DATE].
-He/she had a diagnosis of generalized anxiety disorder (excessive, exaggerated anxiety and worry about everyday life events with no obvious reasons for worry).
Record review of the resident's October 2019 Physician's Orders Sheet (POS) showed:
-An order dated 12/16/18 for Alprazolam (antianxiety medication) one (1) milligram (mg) every six hours as needed dated, without a duration time frame or stop date.
-General anxiolytic (antianxiety) PRN every six hours non-pharmacological interventions including redirection, massage, and music, dated 12/31/18.
Record review of the resident's Consultant Pharmacist Medication Regimen Review Communication forms dated 2/19/19 through 9/17/19 showed:
-The facility consultant pharmacist reviewed the resident's medication regimen monthly on 2/19/19, 3/19/19, 4/16/19, 5/21/19, 6/21/19, 7/22/19, 8/20/19 and 9/17/19.
-The facility consultant pharmacist sent communication to the facility psychiatrist on 3/19/19 and on 7/22/19.
Record review of the resident's consultant Pharmacist Medication Regimen Review Communication dated 3/9/19 showed:
-The resident had diagnoses of dementia with hallucinations and anxiety.
-He/she currently received quetiapine (antipsychotic medication) 25 milligrams (mg) at bedtime daily, escitalopram (antidepressant medication) 10 mg daily in the morning and alprazolam 1 mg twice daily.
-Please assess medical risk versus benefit and if the resident would benefit from a gradual dose reduction of one or more therapy agents.
-No mention of the resident's PRN Alprazolam antianxiety medication that was ordered on 12/16/18.
Record review of the resident's consultant Pharmacist Medication Regimen Review Communication dated 7/22/19 showed:
-The resident received Escitalopram (antidepressant medication) 10 milligrams (mg) each day (q day) mirtazapine (antidepressant medication) for depression 15 mg each bedtime (q hs) for depression.
-Please assess if the resident would benefit from a gradual dose reduction of his/her antidepressant medication.
-No mention of the resident's PRN alprazolam antianxiety medication that was ordered on 12/16/18.
Record review of the resident's October 2019 and November 2019 Medication Administration Records (MAR) showed he/she had last received his/her alprazolam 1 mg PRN on 10/21/19.
Observation and interview on 10/31/19 at 2:32 P.M. showed:
-The resident was seated in his/her wheelchair in his/he room and completing a Word Search puzzle.
-He/she was alert, calm and smiling.
-He/she said he/she had been going to activities that morning.
Observation on 11/1/19 at 1:06 P.M. showed:
-The resident was seated in his/her wheelchair in his/her room.
-He/she was smiling and answering questions.
Observation and interview on 11/4/19 at 6:42 A.M. showed:
-The resident was seated in his/her room in his/her wheelchair.
-He/she was alert, dressed, and smiling.
-He/she said he/she liked to be up early.
Observation on 11/419 at 9:01 A.M. showed:
-The resident was propelling himself/herself in his/her wheelchair in his/her living area hallway.
-He/she was dressed, well-groomed and was smiling.
During an interview on 11/5/19 at 9:43 A.M. Certified Nursing Assistant (CNA) E said:
-The resident was easy going and asked for what he/she needed.
-He/she had no behaviors.
-He/she was always smiling and talking.
During an interview on 11/5/19 at 10:09 A.M. Licensed Practical Nurse (LPN) G said:
-The resident had a physician's order for alprazolam 1 mg every six hours.
-The resident will ask for his/her alprazolam when he/she needed it before his/her anxiety got out of hand and he/she had not had alprazolam in November 2019.
-The resident's alprazolam PRN order was dated 12/16/18.
-Usually PRN psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) are usually only written for 90 days for some psychoactive medications.
-He/she had known of a 14 day limit for the original order for PRN psychotropic medications and that if the order was renewed there still needed to be a time frame for the order.
-He/she had not thought about the resident having a time limit for his/her PRN alprazolam.
-He/she now saw that there was no time frame for the resident's PRN alprazolam.
-Had he/she noticed the date of 12/16/19 for the resident's PRN alprazolam, he/he might have called the resident's physician or let the Director of Nursing (DON) know.
During an interview on 11/5/19 at 1:09 P.M. the DON said:
-PRN antianxiety medications have to be looked at and evaluated by the physician every 15 days.
-The residents PRN antianxiety medication not having a duration limit should have been caught by the consultant pharmacist during completion of the resident's monthly drug regimen reviews.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure open dates on opened multi-dose medications, failed to ensure removal of all outdated/expired medications from the medi...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure open dates on opened multi-dose medications, failed to ensure removal of all outdated/expired medications from the medication cart, failed to ensure proper storage of medications and failed to ensure the medication carts were clean and free from medication spillage. The facility census was 104 residents.
Record review of the Medication Storage in the Facility Policy, unsigned, dated 6/2016 showed:
-Medications are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier.
-Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists.
-Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity; and
-Refrigerated medications are kept in closed and labeled containers.
1. Observation on 11/4/19 at 9:56 A.M., of the Certified Medication Technician (CMT) cart for rooms 301-318 showed:
-The following medications without open dates:
--One opened bottle of Ketorolac (nonsteroidal anti-inflammatory drug) ophthalmic (pertaining to the eye) solution, 0.5 percent (%).
--One opened bottle of Lumigan (medication to treat glaucoma (a condition of increased pressure inside the eye which could lead to blindness)) ophthalmic solution, 0.01%.
--Calcitonin-Salmon (medication to treat bone loss due to osteoporosis) 200 international units and
-An opened bottle of Pro Source Plus 15 gram (gm-a high protein nutritional supplement) with red sticky substance dripping down the side of the bottle.
Observation on 11/4/19 at 10:35 A.M., on the CMT cart for rooms 401-420 showed:
-The following medications without open dates:
--One opened bottle of Travatan (medication to treat glaucoma) ophthalmic solution, 0.004%.
--One opened bottle of Fluticasone (nasal spray for allergies), 50 micrograms (mcg).
--One opened bottle of Artificial Tears.
-An opened bottle of Pro Source Plus with red sticky substance dripping down the side of the bottle and into the bottom of the drawer and
-A crystalline appearing powder in the bottom of two drawers.
Observation on 11/4/19 at 11:06 A.M., in the medication room on the 400 unit showed:
-Two opened, 10 milliliter (ml) vials of Lidocaine (medicine to numb the skin) 1% without open dates.
-One opened bottle of Neomycin and Polymyxin irrigation solution (antibiotic solution used for irrigation) which expired 10/15/19.
-Six, 60 milligram (mg) syringes of Lovenox (medication used to prevent pulmonary blood clots and deep vein blood clots) in a drawer for unused sterile syringes.
Observation on 11/4/19 at 12:10 P.M., on the nurse's cart for rooms 301-313 showed, one opened vial of Novolin 70/30 insulin without an open date.
During an interview on 11/4/19 at 10:00 A.M. CMT A said:
-He/she checked the cart every month or so.
-Expired medications should be removed and disposed of properly.
-Open dates need to be on all multi-dose vials/bottles.
-He/she cleaned up spills inside the cart immediately and
-Medications are not to be stored with supplies.
During an interview on 11/4/19 at 11:30 A.M. Licensed Practical Nurse (LPN) A said:
-The multi-dose vials/bottles should be dated with the open date.
-No expired medications should be on the medication cart or medication refrigerator.
-Medication should not be intermingled with supplies.
-He/she checked the medication cart weekly for expired medications and checked medications to ensure they were marked with open dates during every medications pass.
-He/She was unsure how often the medication refrigerator was checked and
-Staff should clean up all spills on the medication cart immediately.
During an interview on 11/4/19 at 12:00 P.M. the 400 Unit Manager said:
-All opened multi-dose vials/bottles are to have an open date written on the container.
-No expired medications should be on the medication carts or in the medication room.
-The medication room was checked every night for expired medications.
-Lovenox was not to be in the syringe drawer and
-He/she expected all medication carts to be free from spills.
During an interview on 11/4/19 at 12:10 P.M. LPN B said:
-Open dates need to be present on all multi-dose vials/bottles.
-He/she expected expired medications to be removed from the cart immediately and
-He/she does a weekly cart check to check for open dates, expired medications and cleanliness of the cart
During an interview on 11/5/19 at 1:09 P.M. the Director of Nursing (DON) said he/she:
-Did not expect to find expired medications on the medication carts.
-Did expect all multi-dose vials/bottles to have open dates on the containers.
-Did expect all medications carts to be clean and free of spills and
-Did not expect to find full Lovenox Syringes in with floor stock syringes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete appropriate hand washing and glove changing d...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete appropriate hand washing and glove changing during perineal care for two sampled residents (Residents #94 and #211); during catheter (a tube passed through the urethra into the bladder to drain urine) care for one sampled resident (Resident #303); during medication pass for three supplemental residents (Resident # 77, #20, and #93), and to properly clean/sanitize community equipment used for one sampled resident who was on isolation (Resident #334) out of 21 sampled residents. The facility census was 104 residents.
Record review of the facility's unsigned handwashing Policy, dated as revised on 5/28/15 showed:
-Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of standard precautions (a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status) and
-Staff were to wash hands before and after contact with each resident, and before and after removal of gloves.
Record review of the Infection Control Policy dated as revised on 5/28/15 showed staff were to wash their hands before and after contact with each resident.
Record review of the Infection Control and Isolation Policy, dated as revised on 10/1/08 showed:
-Change gloves after contact with infective material (i.e., sputum, fecal material, urine, and wound drainage).
-When possible, dedicate the use of non-critical resident-care equipment and items such as a stethoscope, blood pressure cuff, and thermometer to a single resident to avoid sharing between residents.
-If equipment must be used among residents, then they must be adequately clean and disinfected before another resident use.
-Care will be provided to assure appropriate use of barriers to protect all employees and residents from potentially infectious body substances.
-Wash hands immediately after gloves are removed between resident contacts.
-Wear gloves when touching blood, body fluids, secretions, excretions and contaminated items.
-Put on clean gloves just before touching mucous membranes and non-intact skin.
-Removing gloves promptly after use-before touching anything else.
-Wash immediately after removing gloves and
-Ensure that reusable equipment is not used for the care pf another resident until it is appropriately cleaned and disinfected.
1. Record review of Resident #303's Face Sheet showed he/she was admitted to the facility on [DATE], and readmitted on [DATE] with the following diagnoses:
-Chronic kidney disease (kidneys are damaged and can't filter blood the way they should).
-Enterocolitis due to Clostridium Difficile (inflammation of both the small and large intestines, frequently caused by Clostridium Difficile (bacteria which can cause life threatening inflammation of the colon) and
-Muscle weakness.
Record review of the resident's Physician Order Sheets (POS) dated 10/1/19 through 10/31/19 and 11/1/19 through 11/5/19 showed he/she was on Contact Isolation starting 10/17/19 to current.
Observation on 11/1/19 at 1:15 P.M. of peri/catheter care showed Certified Nursing Assistant (CNA) B:
-Washed his/her hands and put on gown and gloves.
-Placed a towel barrier on the resident's over-bed table.
-Removed the resident's brief.
-Did not remove gloves, wash his/her hands and put on new gloves.
-With contaminated gloves, removed three wipes from the wipes container and laid them on the barrier.
-With contaminated gloves obtained a contaminated wipe and wiped the left groin from front to back.
-With contaminated gloves obtained a contaminated wipe and wiped the right groin from front to back.
-With contaminated gloves obtained a contaminated wipe and wiped the center of the perineal area (genital) from front to back.
-With contaminated gloves obtained a contaminated wipe and wiped the catheter from insertion site outward for three inches.
-Removed the gloves, washed his/her hands and put on new gloves.
-Obtained a wipe from the contaminated container.
-With contaminated gloves and wipe, wiped right side of bottom.
-With contaminated gloves, obtained a wipe from the contaminated container and wiped the right side of the resident's bottom; and
-With contaminated gloves, obtained a wipe from the contaminated container and wiped the left side of the resident's bottom.
2. Record review of Resident #94's Face Sheet showed he/she was admitted to the facility on [DATE], and readmitted on [DATE] with the following diagnoses:
-Stroke affecting the left side and
-Chronic kidney disease.
Observation on 11/1/19 at 1:31 P.M. of peri-care showed:
-CNA C and CNA D washed their hands and put on gloves.
-CNA D removed the resident's brief.
-CAN D did not remove the gloves, wash his/her hands and put on new gloves.
-CNA D with contaminated gloves, obtained a wipe from the container and wiped the left groin from front to back.
-CNA D with contaminated gloves, obtained a wipe from the contaminated container and wiped the resident's right groin from front to back.
-CNA D with contaminated gloves, removed a wipe from the contaminated container and wiped the resident's peri-area from front to back.
-CNA D with contaminated gloves, assisted resident to roll to side.
-CNA C removed a wipe from the contaminated container and handed it to CNA D.
-CNA D with contaminated gloves and contaminated wipe, wiped the right side of bottom from front to back.
-CNA C with contaminated gloves, removed a wipe from the contaminated container and handed it to CNA D.
-CNA D with contaminated gloves and contaminated wipe, wiped the left side of bottom from front to back.
-CNA C with contaminated gloves, removed a wipe from the contaminated container and handed it to CNA D.
-CNA D with contaminated gloves and contaminated wipe, wiped the center of bottom from front to back.
-CNA D and CNA C removed gloves, sanitized hands and put on new gloves.
-CNA D with clean gloves closed the contaminated wipes container and gathered trash and
-CNA D and CNA C removed their gloves and washed their hands.
During an interview on 11/1/19 at 1:42 P.M. CNA D said:
-He/she would not do anything differently.
-If anything was touched within the environment the gloves were contaminated and needed to be changed.
-He/she normally pulled wipes out of the container and placed them on the barrier during set up; and
-Hands were considered contaminated after touching the resident and gloves needed to be changed before obtaining wipes out of the container.
During an interview on 11/1/19 at 1:48 P.M. CNA B said:
-He/she would not do anything differently.
-His/her gloved hands were contaminated after removing the resident's brief and his/her gloves needed to be changed and
-Gloves needed to be changed after set up of supplies and before the peri/cath care started.
3. Record review of Resident #211's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Urinary Tract Infection (UTI).
-Urinary incontinence.
-Chronic kidney disease and
-Muscle weakness.
Observation on 11/1/19 at 2:26 P.M. of peri-care showed:
-CNA E and the Assistant Director of Nursing (ADON) both washed their hands and put on gloves.
-CNA E obtained a chux (a water proof barrier) from the resident's drawer and placed it on the resident's bed.
-CNA E with contaminated gloves removed wipes from the container and laid them on the barrier.
-CNA E with contaminated gloves obtained a wipe and wiped the left groin from front to back.
-CNA E with contaminated gloves obtained a wipe and wiped the right groin from front to back.
-CNA E with contaminated gloves obtained a wipe and wiped the peri-area from front to back.
-CNA E removed the gloves, washed his/her hands and put on new gloves.
-CNA E obtained a wipe from the contaminated barrier and wiped the right side of the bottom from front to back.
-CNA E with contaminated gloves, obtained a wipe from the contaminated barrier and wiped the left side of the bottom from front to back.
-CNA E with contaminated gloves, obtained a wipe from the contaminated barrier and wiped the center of the bottom from front to back.
-CNA E with contaminated gloves, cream from the tube and applied to the resident's inner thighs.
-CNA E with contaminated gloves, recapped the contaminated tube of cream and placed it in the resident's drawer.
-CNA E removed the gloves and washed his/her hands and
-The ADON assisted with the rolling of the resident.
During an interview on 11/5/19 at 10:18 A.M. CNA A said:
-He/she would pull wipes out of the container and place onto a clean barrier, so he/she would not use contaminated gloved hand to obtain wipes from the wipes container; and
-Do not touch anything with gloved hands.
During an interview on 11/5/19 at 10:23 A.M. Licensed Practical Nurse (LPN) C said:
-It was appropriate to remove wipes from the container when gloves are clean and
-After touching the resident or anything within the environment gloves are considered contaminated and should be changed and hands washed.
During an interview on 11/5/19 at 10:30 A.M. the 400 hall Unit Manager said:
-After touching the resident or anything within the environment the gloved hands would be considered contaminated and
-Gloves would need to be changed, otherwise the whole container of wipes would be considered contaminated.
During an interview on 11/5/19 at 1:09 P.M. the DON said he/she would not expect staff to obtain wipes out of the container with contaminated gloves.
4. Observation on 11/4/19 at 6:46 A.M. of medication pass showed:
-Certified Medication Technician (CMT) C did not wash or sanitize his/her hands.
-CMT C with contaminated hands dispensed and administered medications to
Resident #77.
-CMT C returned to the medication cart.
-CMT C did not wash or sanitize his/her hands.
-With contaminated hands, CMT C dispensed and administered medications to Resident #20.
-CMT C returned to the medication cart.
-CMT C did not wash or sanitize his/her hands and
-With contaminated hands, CMT C dispensed and administered medications to Resident #93.
During an interview on 11/5/19 at 10:23 A.M. LPN C said:
-Hands were to be washed before handling any medications and
-Hands were to be sanitized or washed between each resident.
During an interview on 11/5/19 at 10:30 A.M. the 400 Unit Manager said:
-He/she expected hands to be sanitized between each resident's medication pass and
-He/she expected hands to be washed after every third resident.
During an interview on 11/5/19 at 1:09 P.M. the DON said, he/she expected staff passing medications to sanitize their hands between every resident and wash their hands after every third resident.
5. Observation on 11/4/19 at 6:57 A.M. during medication pass for Supplemental Resident #93 showed:
-The resident was on contact isolation and had an isolation cart in the hallway outside his/her room.
-CMT C sanitized his/her hands, put on a gown and gloves.
-CMT C obtained the community thermometer and a disposable kit stethoscope and took them into the resident's room.
-CMT C placed the community thermometer onto the resident's contaminated over the bed table.
-CMT C opened and assembled the disposable kits stethoscope.
-CMT C obtained the resident's vital signs and set the contaminated community thermometer onto the resident's contaminated over bed table.
-CMT C administered the resident's medications.
-CMT C removed the gown and gloves and disposed of them in the red trash bins.
-CMT C washed his/her hands and
-CMT C picked up the contaminated community thermometer from the contaminated over bed table and took it out of the isolation room and placed it onto the medication cart.
During an interview on 11/5/19 at 10:18 A.M., CNA A said:
-A disposable thermometer should be used on residents who are in isolation.
-The community thermometer should not be taken into an isolation room.
-If the community thermometer was taken into an isolation room it should not be placed in the medication cart without cleaning/disinfecting it first and
-The community thermometer could be cleaned/disinfected with bleach wipes and kept moist for four minutes.
During an interview on 11/5/19 at 10:23 A.M. LPN C said:
-The community thermometers are not to be used in isolation rooms.
-The facility had disposable kits which contained a blood pressure cuff, stethoscope and thermometer to be used for residents in isolation.
-If the community thermometer was used in an isolation room with extended-spectrum beta-lactamases (ESBL-a chemical produced by bacteria that break down several types of antibiotics making the infection harder to treat).
--The thermometer would be cleaned immediately before leaving the room with a bleach wipe.
--The thermometer must stay wet with the bleach wipe for four minutes and
-When the community thermometer is removed from the room it should never be placed on top of the medication cart.
During an interview on 11/5/19 at 10:30 A.M. the 400 Unit Manager said:
-The facility had one-time use/disposable equipment to use in isolation rooms.
-If the community thermometer was taken into an isolation room:
--It could be cleaned with bleach wipes.
--Must be cleaned before leaving the room.
--Should be cleaned again after leaving the room and
--He/she would throw it away.
During an interview on 11/5/19 at 1:09 P.M. the DON said:
-The facility had disposable kits for residents in isolation which included a thermometer.
-He/she expected the medication carts to be free of medication spillage and dirt and
-He/she did not expect the community thermometer to be placed on the medication cart without being properly disinfected.
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), 1 harm violation(s), $27,560 in fines. Review inspection reports carefully.
- • 34 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $27,560 in fines. Higher than 94% of Missouri facilities, suggesting repeated compliance issues.
- • Grade F (28/100). Below average facility with significant concerns.
Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Jackson Creek Post Acute's CMS Rating?
CMS assigns JACKSON CREEK POST ACUTE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Jackson Creek Post Acute Staffed?
CMS rates JACKSON CREEK POST ACUTE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, compared to the Missouri average of 46%. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Jackson Creek Post Acute?
State health inspectors documented 34 deficiencies at JACKSON CREEK POST ACUTE during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 32 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 Jackson Creek Post Acute?
JACKSON CREEK POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NATIONAL HEALTHCARE CORPORATION, a chain that manages multiple nursing homes. With 120 certified beds and approximately 100 residents (about 83% occupancy), it is a mid-sized facility located in INDEPENDENCE, Missouri.
How Does Jackson Creek Post Acute Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, JACKSON CREEK POST ACUTE's overall rating (2 stars) is below the state average of 2.5, staff turnover (55%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Jackson Creek Post Acute?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Jackson Creek Post Acute Safe?
Based on CMS inspection data, JACKSON CREEK POST ACUTE 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 2-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Jackson Creek Post Acute Stick Around?
JACKSON CREEK POST ACUTE has a staff turnover rate of 55%, which is 9 percentage points above the Missouri average of 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 Jackson Creek Post Acute Ever Fined?
JACKSON CREEK POST ACUTE has been fined $27,560 across 1 penalty action. This is below the Missouri average of $33,354. 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 Jackson Creek Post Acute on Any Federal Watch List?
JACKSON CREEK POST ACUTE 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.