HUBBLE CREEK
For profit - Corporation
105 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
8/100
#251 of 479 in MO
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Hubble Creek in Jackson, Missouri, has received a Trust Grade of F, indicating significant concerns about the facility's overall quality and care. With a rank of #251 out of 479 in the state, they fall within the bottom half of Missouri nursing homes, and #7 out of 8 in Cape Girardeau County means only one local option is slightly better. The facility is showing improvement, with issues decreasing from 25 in 2023 to 14 in 2024, but it still faces serious challenges, including $52,622 in fines, which is concerning and higher than 80% of other facilities in Missouri. While staffing is average with a 3/5 star rating, the 64% turnover rate is a red flag, and the RN coverage is below average, being less than 78% of state facilities, which may impact the quality of care. Recent inspections revealed critical failures in infection control practices, such as staff not performing proper hand hygiene, and serious incidents where a resident was not transferred safely, resulting in a fracture, highlighting both weaknesses and the need for significant improvements in care protocols.
- Trust Score
- F
- In Missouri
- #251/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 64% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $52,622 in fines. Higher than 68% of Missouri facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
8/100
Bottom 48%
Review needed
25 → 14 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 25 issues
2024: 14 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Near Missouri average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 64%
18pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $52,622
Above median ($33,413)
Moderate penalties - review what triggered them
Staff turnover is elevated (64%)
16 points above Missouri average of 48%
The Ugly 52 deficiencies on record
1 life-threatening 3 actual harm
Nov 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. This de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 45.
The facility did not provide an environment policy.
1. Observation on 11/05/24 at 10:35 A.M., showed room [ROOM NUMBER] with a one foot (ft) by six inches (in) hole in the dry wall on the right side of the window.
2. Observation on 11/05/24 at 10:48 A.M., of room [ROOM NUMBER] showed:
- A hole in the dry wall at the foot of the bed three in by six in;
- A hole in the dry wall under the bathroom sink three in by six in;
- Missing dry wall which exposed the metal corner mold along the wall by the bathroom door;
- Multiple scraped areas of the dry wall along the wall by the room exit door.
During an interview on 11/05/24 at 10:49 A.M., the resident in room [ROOM NUMBER] said he/she was unsure how long the walls had been like this but at least a few months.
3. Observation on 11/05/24 at 10:50 A.M., showed a two ft missing section of base cove around the corner of room [ROOM NUMBER].
During an interview on 11/08/24 at 12:30 P.M., the Maintenance Director said he/she had forms to fill out if something needed fixed but most of the time, everyone just told him/her if something needed fixed or looked at.
During an interview on 11/08/24 at 1:33 P.M., the Administrator said she would expect the building to be in good repair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility initiated transfer when two residents (Residents #6 and #30) out of five sampled residents transferred to the hospital. The facility's census was 45.
Review of facility policy titled, Discharge/Transfer of Resident, undated, showed:
- Give copy of a signed transfer or discharge notice to the resident and/or representative or person responsible for care;
- If an emergency transfer, a transfer or discharge notice form may be completed later, but as soon as possible.
1. Review of Resident #6's medical record showed:
- The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE];
- No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE].
2. Review of Resident #30's medical record showed:
- The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE];
- No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE].
During an interview on 11/08/24 at 11:28 A.M., the Director of Nursing (DON) said they had not been able to find any transfer/discharge notices.
During an interview on 11/08/24 at 1:33 P.M., the Administrator said she would expect transfer/discharge notices to be given when residents transfer to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record view, the facility failed to inform the resident and/or the resident's representative of the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record view, the facility failed to inform the resident and/or the resident's representative of the facility bed hold policy at the time of transfer to the hospital for two residents (Residents #6 and #30) out of five sampled residents. The facility's census was 45.
Review of facility policy titled, Discharge/Transfer of Resident, undated, showed:
- Explain and give a copy of the bed hold form to the resident and/or representative.
1. Review of Resident #6's medical record showed:
- The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer.
2. Review of Resident #30's medical record showed:
- The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE];
- No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer.
During an interview on 11/08/24 at 11:28 A.M., the Director of Nursing (DON) said bed hold policies prior to her and the Administrator starting at the facility were not found.
During an interview on 11/08/24 at 1:33 P.M., the Administrator said she would expect bed hold policies were to be given when residents transfer to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident haza...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in seven occupied resident room sinks and two community showers, which put the residents at an increased risk of injuries from exposure to the hot water. These practices had the potential to affect all the residents at the facility. The facility census was 45.
The facility did not provide a policy regarding water temperatures.
Review of the Burn Foundation website showed hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters:
- In one second at 156 degrees F;
- In two seconds at 149 degrees F;
- In five seconds at 140 degrees F;
- In 15 seconds at 133 degrees F;
- In one minute at 127 degrees F.
Observation on 11/05/24 at 12:15 P.M. through 12:33 P.M., of water temperatures taken at 60 seconds with a digital thermometer showed:
- room [ROOM NUMBER] hot water temperature recorded at 128 degrees F;
- room [ROOM NUMBER] hot water temperature recorded at 132 degrees F;
- room [ROOM NUMBER] hot water temperature recorded at 124 degrees F;
- room [ROOM NUMBER] hot water temperature recorded at 129 degrees F;
- The 400 Hall shower room water temperature recorded at 122 degrees F.
Observation on 11/08/24 at 10:04 A.M. through 10:15 A.M., of water temperatures taken at 60 seconds with a digital thermometer showed:
- room [ROOM NUMBER] water temperature recorded at 141 degrees F;
- room [ROOM NUMBER] water temperature recorded at 129 degrees F;
- room [ROOM NUMBER] water temperature recorded at 129 degrees F;
- room [ROOM NUMBER] water temperature recorded at 131 degrees F;
- The 500 Hall shower room water temperature recorded at 124 degrees F.
Observation on 11/08/24 at 10:18 A.M., of the mechanical room on the 200 Hall showed one hot water heater with two non-digital external thermometers for monitoring and setting the temperatures. Both thermometers showed temperatures of 122 degrees F.
Observation on 11/08/24 at 10:20 A.M., of the mechanical room on the 100 Hall showed one hot water heater with two non-digital external thermometers for monitoring and setting the temperatures. The first thermometer showed 140 degrees F and the second thermometer showed 130 degrees F.
Observation on 11/08/24 at 10:22 A.M., of the mechanical room on the 400 Hall showed one hot water heater with two non-digital external thermometers for monitoring and setting the temperatures. Both thermometers showed temperatures of 132 degrees F.
During an interview on 11/05/24 at 2:34 P.M., Certified Nurse Assistant (CNA) F said no residents had reported the water being too hot or being scalded by the water on the 400 Hall.
During an interview on 11/08/24 at 10:50 A.M., the resident in room [ROOM NUMBER] said the water had been really cold but today it was scalding hot.
During an interview on 11/08/24 at 10:00 A.M., the Maintenance Supervisor said the plumber was at the facility yesterday and fixed the water heater pump for the 100 Hall. The plumber set the the hot water heater thermometer at 125 degrees F.
During an interview on 11/20/24 at 10:30 A.M., the Administrator said she expected the water temperatures in the resident rooms and resident care areas to be between 105 and 120 degrees F.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated when changed for one resident (Resident #12) and failed to ensure a physician's order for oxyg...
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Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated when changed for one resident (Resident #12) and failed to ensure a physician's order for oxygen with the use of a bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) was followed for one resident (Resident #195) out of two sampled residents. The facility census was 45.
Review of the facility's policy titled, Oxygen Administration, undated, showed:
- The purpose is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues;
- Prefilled disposable humidifiers may be changed when empty;
- Set the flow meter to the rate ordered by the physician;
- Label the humidifier with the date and time opened;
- Change humidifier and tubing per cleaning guidelines;
- At regular intervals, check and clean the oxygen equipment, masks, tubing and cannulas;
- At regular intervals, check the liter flow contents of the oxygen cylinder, fluid level in the humidifier, and assess the resident's respiration.
Review of the facility policy titled, Physician Orders, undated, showed oxygen orders must specify the rate of flow, route, and rationale for use.
1. Review of Resident #12's medical record showed:
- admission date of 10/16/24;
- Diagnoses of chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems) and chronic kidney disease (kidneys do not filter waste and fluid like they should).
Review of the resident's Physician Order Sheet (POS), dated October 2024, showed:
- An order for oxygen at 2 liters per minute (LPM) by nasal cannula (NC - a flexible tube inserted into the nose to administer supplemental oxygen) as needed for shortness of breath, dated 08/13/24;
- An order to change oxygen tubing monthly on the first of the month, dated 08/13/24.
Observation of the resident on 11/06/24 at 2:42 P.M., showed the resident sat on the side of the bed with oxygen on at 2 LPM via NC and the oxygen tubing was not dated.
Observation of the resident on 11/08/24 at 9:29 A.M., showed the resident sat in the wheelchair with oxygen on at 2 LPM via NC and the oxygen tubing was not dated.
During an interview on 11/06/24 at 2:43 P.M., Resident #12 said the nurses changed the tubing but was unsure when it was changed last.
2. Review of Resident #195's medical record showed:
- admission date of 10/16/24;
- Diagnoses of acute respiratory failure, heart failure (heart not pumping as it should), and chronic kidney disease.
Review of the resident's POS, dated October 2024, showed:
- An order for oxygen at 2 LPM by NC continuous, dated 10/18/24;
- No order for BIPAP.
Review of the resident's care plan, revised 10/23/24, showed:
- Administer oxygen as prescribed;
- Did not address the BIPAP.
Observation on 11/06/24 at 10:15 A.M., showed Resident #195 lay in bed sleeping on his/her left side with a BIPAP and 2 LPM of oxygen bled in.
Observation on 11/06/24 at 11:55 A.M., showed the resident sat on the side of the bed and did not wear oxygen.
Observation on 11/07/24 at 10:28 A.M., showed the resident sat on the side of the bed and did not wear oxygen. Two staff were assisting the resident with a dressing change.
Observation on 11/08/24 at 10:45 A.M., showed the resident sat in a wheelchair, did not wear oxygen, and one staff in the room.
During an interview on 11/08/24 at 8:20 A.M., Registered Nurse (RN) I said he/she thought Resident #195 was supposed to have oxygen 2 LPM bled into the BIPAP. He/She couldn't find an order for the resident's BIPAP with the settings.
During an interview on 11/08/24 at 12:02 P.M., RN G said nurses were responsible for BIPAP equipment and changing the tubing monthly.
During an interview on 11/08/24 at 12:35 P.M., the Director of Nursing (DON) said nurses were responsible for managing the BIPAP and for changing the tubing monthly. There should be an order for the BIPAP with the settings.
During an interview on 11/08/24 at 1:33 P.M., the DON and Administrator said they would expect the resident to have an order for the BIPAP use including the settings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure two nurse aides (NAs) (NA B and NA C) completed a nurse aide training program within four months of his/her employment in the facili...
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Based on interview and record review, the facility failed to ensure two nurse aides (NAs) (NA B and NA C) completed a nurse aide training program within four months of his/her employment in the facility out of two sampled NAs. This deficient practice had the potential to affect all residents in the facility. The facility census was 45.
The facility did not provide a policy on the nurse aide training program.
1. Review of NA B's Training Record showed:
- Hire date of 06/12/24;
- NA B attended an online nurse aide program;
- The facility failed to ensure the completion of the program within four months of the hire date.
2. Record review of NA C's Training Record showed:
- Hire date of 06/25/24;
- NA C attended an online nurse aide program;
- The facility failed to ensure the completion of the program within four months of the hire date.
During an interview on 11/07/24 at 9:30 A.M., the Director of Nursing (DON) said the currently employed NAs were taking nurse aide training through an online program. She thinks NA B and NA C had completed the program and were waiting on permission to take their tests.
During an interview on 11/07/24 at 9:45 A.M., the Administrator said she would expect NAs to complete a nurse aide training program within four months of their hire date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide nurse aide's annual individual performance review or evaluation, and failed to provide annual in-service training based on the outc...
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Based on interview and record review, the facility failed to provide nurse aide's annual individual performance review or evaluation, and failed to provide annual in-service training based on the outcome of performance reviews for two Certified Nurse Assistants (CNAs) (CNA D and CNA E) out of two sampled CNAs. The facility census was 45.
The facility did not provide a policy on CNA performance review and training requirements.
1. Review of CNA D's in-service record showed:
- CNA D with a hire date of 02/22/22;
- CNA D did not receive an annual individual performance review or evaluation;
- No annual in-service training for February 2023 through February 2024.
2. Review of the CNA E's in-service record showed:
- CNA E with a hire date of 02/18/15;
- CNA E did not receive an annual individual performance review or evaluation;
- No annual in-service training for February 2023 through February 2024.
During an interview on 11/07/24 at 9:00 A.M., the Administrator said no employee performance reviews or evaluations had been done since she started in May 2024, and there was no documentation they had been done prior to her employment either.
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 an appropriate diagnosis for the use of an antipsychotic (me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic (medications that treat psychosis-related conditions and symptoms) medication for one resident (Resident #37) out of five sampled residents. The facility census was 45.
Review of the facility's policy titled, Antipsychotic Medication Use, not dated, showed:
- Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective;
- Antipsychotic medications shall only be used for the following conditions/diagnoses as documented in the record: schizo-affective disorder (a chronic mental illness that combines symptoms of schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors) and a mood disorder (a mental health condition that involves a persistent change in a person's emotional state)), mood disorders, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) with psychotic (a severe mental disorder that causes a person to lose touch with reality) features, psychosis not otherwise specified, brief psychotic disorder, schizophrenia , delusional disorder (a psychiatric condition characterized by a person having one or more fixed false beliefs), schizophreniform disorder (a mental health condition that causes symptoms similar to schizophrenia, but for a shorter period of time), atypical psychosis, dementing (causing or characterized by dementia, a disease that can cause memory loss, confusion, and disorientation) illness with associated behavioral symptoms.
1. Review of Resident #37's medical record showed:
- admitted to the facility on [DATE];
- Diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), generalized anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression, and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep);
- An order for olanzapine (an antipsychotic medication) 2.5 milligrams (mg) at bedtime for insomnia, dated 08/21/24;
- No documentation for an appropriate diagnosis for the olanzapine.
Review of the resident's Pharmacist monthly Medication Regimen Review (MRR) for September and October 2024 showed:
- No recommendation for an appropriate diagnosis for the olanzapine.
During an interview on 11/07/24 at 2:30 P.M., the Director of Nursing (DON) said insomnia was not an appropriate diagnosis for an antipsychotic medication.
During an interview on 11/19/24 at 12:38 P.M., Pharmacist N said insomnia was not an appropriate diagnosis for an antipsychotic medication. Physician orders were reviewed on a monthly basis, but Resident #37's olanzapine was not due for a gradual dose reduction yet, so it may not have been reviewed during the MRR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 32 opportunities with two e...
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Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 32 opportunities with two errors made, for an error rate of 6.25%, which affected two residents (Residents #33 and #195) out of six sampled residents. The facility census was 45.
The facility did not provide a medication error policy.
Review of the insulin aspart manufacture guidelines for giving the airshot (prime) before each injection and administration, revised 02/2023, showed:
- Turn the dose selector to select 2 units;
- Hold the pen with the needle pointing up;
- Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge;
- Keep the needle pointing upwards, press the push-button all the way in;
- The dose selector returns to zero;
- A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times;
- Select your dose.
1. Review of Resident #33's Physician Order Sheet (POS), dated November 2024, showed an order for insulin aspart 18 units subcutaneous (an injection under the skin) at 7:00 A.M., 12:00 P.M., and 5:00 P.M., with meals every day, dated 09/30/24.
Observation on 11/06/24 at 11:45 A.M., of the resident's insulin aspart administration showed Registered Nurse (RN) G failed to prime the insulin aspart pen before administering the 18 units.
2. Review of Resident #195's POS, dated November 2024, showed an order for insulin aspart 10 units subcutaneous at 7:00 A.M., 12:00 P.M., and 5:00 P.M., with meals every day, dated 10/16/24.
Observation on 11/06/24 at 11:59 A.M., of the resident's insulin aspart administration showed RN G failed to prime the insulin aspart pen before administering the 10 units.
During an interview on 11/06/24 at 11:46 A.M., RN G said he/she primed the insulin pens the first time they were used. The insulin pens didn't require priming after the first use.
During an interview on 11/08/24 at 1:35 P.M., the Director of Nursing (DON) and the Administrator said they would expect staff to administer medications according to the manufacturer's guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These...
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Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect the thirteen residents who were served food from the 400 Hall refrigerator. The facility census was 45.
Review of facility policy titled, Receiving and Storage of Food, dated May 2015, showed:
- All perishable items are stored in either refrigerators at a temperature of 40 degrees Fahrenheit (F) or below or freezers at a temperature of 0 degrees F or below.
The facility did not provide refrigerator temperatures for the 400 Hall.
1. Observation on 11/07/24 at 12:10 P.M., of the 400 Hall unit refrigerator showed:
- A temperature of 50 degrees F;
- An opened container of milk, unlabeled and undated;
- A pitcher of a purple liquid, unlabeled and undated;
- An unopened container of yogurt.
2. Observation on 11/07/24 at 2:00 P.M., of the 400 Hall unit refrigerator showed:
- A temperature of 50 degrees;
- An opened container of milk, unlabeled and undated;
- An unopened container of yogurt.
3. Observation on 11/08/24 at 8:56 A.M., of the 400 Hall unit refrigerator showed:
- A temperature of 50 degrees;
- An opened container of milk, unlabeled and undated;
- A pitcher of yellow liquid, unlabeled and undated;
- A pitcher of red liquid, unlabeled and undated.
During an interview on 11/07/24 at 12:19 P.M., Nurse Aide (NA) B said the refrigerator on the 400 Hall was mainly used for employee's food but it was also used to store the residents' leftover drinks from meals. Maintenance monitored the refrigerator temperatures.
During an interview on 11/07/24 at 12:19 P.M., Certified Nurse Aide (CNA) A said he/she brought the opened milk container over from the kitchen, but did not date the container when it was opened.
During an interview on 11/07/24 at 3:50 P.M., the Maintenance Supervisor said he/she monitored the temperatures for the unit refrigerators and keeps a log which was kept in the kitchen.
During an interview on 11/08/24 at 9:19 A.M., the Dietary Manager said he/she did not keep logs of the unit refrigerators and staff should be dating the milk when the containers were opened.
During an interview on 11/8/24 at 1:33 P.M., the Administrator said she would expect unit refrigerator temperatures to be checked regularly and to be maintained below 41 degrees F.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the quality assessment and assurance (QAA) committee attendees included an Infection Preventionist (IP). This failure had the potent...
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Based on interview and record review, the facility failed to ensure the quality assessment and assurance (QAA) committee attendees included an Infection Preventionist (IP). This failure had the potential to affect all 45 residents who reside at the facility. The facility's census was 45.
The facility did not provide a policy regarding the QAA Committee.
The facility did not provide QAA Committee Attendance records prior to September 2024.
Review of the QAA Committee Attendance record, dated September 2024, showed the IP did not attend the meeting as required.
During an interview on 11/06/24 at 8:50 A.M., the Administrator said the IP did not attend the QAA meeting because he/she had been working as the charge nurse on the night shift. She did not have the QAA Committee Attendance records prior to September 2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment by not wearin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment by not wearing source control (facemasks) during a Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 - a member of a large family of viruses called coronaviruses) outbreak. This deficient practice had the potential to affect all residents in the facility. The facility's census was 45.
Review of the Infection Control Guidance, provided by the Centers for Disease Control and Prevention (CDC), updated on 05/08/23, showed:
- Source control is recommended for those working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of a respiratory infection;
- Universal use of source control could be discontinued once the outbreak is over;
- Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility.
Review of the facility's policy titled, Outbreak Management, SARS-CoV-2 for Long Term Care Facilities, last revised 05/15/23, showed:
- The strategies CDC recommends to prevent the spread of SARS-CoV-2 in long term care communities are the same strategies used every day to detect and prevent the spread of other respiratory viruses like influenza;
- Ensure facility staff are educated, trained, and have practiced the appropriate use of personal protective equipment (PPE) prior to caring for a resident;
- Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing;
- Source control is recommended for those working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection.
1. Observations on 11/05/24 showed:
- At 9:55 A.M., no sign posted on the entry door indicating the facility in COVID 19 outbreak status;
- At 9:57 A.M., no signs indicating isolation on the rooms of the COVID 19 positive residents;
- At 9:58 A.M., Licensed Practical Nurse, (LPN) L sat at the desk without a face covering or mask;
- At 10:00 A.M., LPN M placed isolation gowns on the isolation cart outside of the COVID 19 positive rooms, and returned to the common area with other residents present, without a face covering or mask;
- At 12:23 P.M., staff assisted residents in the dining room without face coverings or masks.
2. Observations on 11/06/24 showed:
- At 8:46 A.M., Certified Medication Technician (CMT) H failed to wear a mask when administering medications to residents in the common area;
- At 8:58 A.M., CMT H failed to wear a mask when administering medications to residents in the common area;
- At 9:16 A.M., CMT H failed to wear a mask when administering medications in room [ROOM NUMBER];
- At 9:20 A.M., CMT H failed to wear a mask when administering medications to residents in the common area on the locked unit;
- At 11:32 A.M., Registered Nurse (RN) G failed to wear a mask when checking a blood sugar in room [ROOM NUMBER];
- At 11:37 A.M., RN G failed to wear a mask when checking a blood sugar in room [ROOM NUMBER];
- At 11:40 A.M., RN G failed to wear a mask when checking a blood sugar in room [ROOM NUMBER];
- At 11:45 A.M., RN G failed to wear a mask when checking blood sugar and administering insulin in room [ROOM NUMBER];
- At 11:59 A.M., RN G failed to wear a mask when administering insulin in room [ROOM NUMBER].
During an interview on 11/05/24 at 10:45 A.M., Housekeeper J said staff had to dress up with the PPE outside the COVID rooms before going in, but no one had said anything about wearing a mask outside the COVID rooms.
During an interview on 11/08/24 at 9:10 A.M., CNA K said no one had said anything about wearing a mask outside the COVID rooms. If he/she needed to go into a COVID room, then needed to wear a faceshield, gown, gloves, and a N95 mask.
During an interview on 11/05/24 at 2:30 P.M., the Director of Nursing (DON) said the facility's protocol at this time was for staff to wear face masks in the isolation rooms only.
During an interview on 11/08/24 at 1:33 P.M., the Administrator and the DON said they expect staff to follow the CDC guidelines during a COVID-19 outbreak.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to conduct at least twelve hours of certified nurse assistant (CNA) in-service education per year and failed to provide the required annual co...
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Based on interview and record review, the facility failed to conduct at least twelve hours of certified nurse assistant (CNA) in-service education per year and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) for two CNAs (CNA D and CNA E) out of two sampled CNAs. The facility census was 45.
The facility did not provide a policy on nurse aide training requirements.
1. Review of Certified Nursing Assistant (CNA) D's in-service record showed:
- A hire date of 02/22/22;
- Did not attend an annual competency in-service training on Dementia Care;
- No annual in-service training for February 2023 through February 2024;
- Less than twelve hours of in-service education for February 2023 through February 2024.
2. Review of CNA E's in-service record showed:
- A hire date of 0218/15;
- Did not attend an annual competency in-service training on Dementia Care;
- No annual in-service training for February 2023 through February 2024;
- Less than twelve hours of in-service education for February 2023 through February 2024.
During an interview on 11/07/24 at 11:30 A.M., the Director of Nursing (DON) said she had started as DON in May 2024, and had been trying to catch staff up on the required training.
During an interview on 11/08/24 at 1:45 A.M., the Administrator said she expects all CNAs to have at least 12 hours of continuing in-service training annually and the training should include training on Dementia Care.
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 resident care for activities of daily living (ADLs) when re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident care for activities of daily living (ADLs) when residents did not receive scheduled showers for three residents (Residents #1, #2, and #3) out of three sampled residents. The facility census was 38.
The facility did not provide a policy regarding shower frequency.
1. Review of Resident #1's medical record showed:
- admission date of 10/23/23;
- Diagnoses of osteoporosis (a decrease in bone mass and density) with fracture, muscle weakness, disc degeneration (a condition in which damaged disc causes pain), history of falling, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), lack of coordination, and frontotemporal neurocognitive disorder (a disorder when nerve cells of parts of the brain are lost, which can affect behavior, personality, language and movement).
Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 01/26/24, showed:
- Moderate cognitive impairment;
- Set up and clean up assistance from staff for upper body dressing and personal hygiene;
- Moderate assistance for lower body dressing, toileting, and shower/bath.
Review of the resident's comprehensive care plan, last revised 11/27/23, showed:
- Resident requires assistance from staff with activities of daily living, incontinent care, and transfers.
Review of the facility's shower schedule showed the resident was scheduled for showers on Mondays and Thursdays.
Review of the resident's shower sheets from 01/01/24 through 02/21/24, showed seven out of 15 opportunities for showers missed.
During an interview on 01/21/23 at 10:55 A.M., the resident said he/she has gone a week at a time without a shower and had to request to get those.
2. Review of Resident #2's medical record showed:
- admission date of 07/01/22;
- Diagnoses of dementia, compression fracture (a type of break in a bone caused by pressure) of the lower back, repeated falls, weakness, high blood pressure, and depressive episodes (a mood disorder that causes a periodic feeling of sadness and loss of interest in activities, causing significant impairment in daily life).
Review of the resident's quarterly MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Maximal assistance of staff for lower body dressing, toileting and shower/bath;
- Moderate assistance for upper body dressing, and personal hygiene.
Review of the resident's comprehensive care plan, last revised on 01/15/24, showed:
- Resident requires assistance from staff with activities of daily living, incontinent care, and transfers.
Review of the facility's shower schedule showed the resident was scheduled for showers on Mondays and Thursdays.
Review of the resident's shower sheets from 01/01/24 through 02/21/24 showed 10 out of 15 opportunities for showers missed.
During an interview on 02/21/24 at 11:10 A.M., the resident said he/she rarely gets a shower, for sure not twice a week.
3. Review of Resident #3's medical record showed:
- admission date of 10/16/23;
- Diagnoses of heart failure, unsteadiness on feet, history of falling, lack of coordination, high blood pressure, and depressive episodes.
Review of the resident's annual MDS, dated [DATE], showed:
- No cognitive impairment;
- Independent for upper and lower dressing, personal hygiene, and toileting;
- Supervisory or touching assistance from staff for shower/bath.
Review of the resident's comprehensive care plan, dated 11/27/23, showed:
- Assistance with activities of daily living was not addressed.
Review of the facility's shower schedule showed the resident was scheduled for showers on Tuesdays and Fridays.
Review of the resident's shower sheets from 02/09/24 through 02/21/24 showed four out of four opportunities for showers missed.
During an interview on 02/21/24 at 11:24 A.M., the resident said he/she has not had a shower since moving to this side of the building, needs assistance from staff with showers since breaking wrist during a fall, and is concerned he/she may have a bad odor due to not having a shower.
During an interview on 01/21/24 at 11:45 A.M., Registered Nurse (RN) A said residents should have a shower twice per week per the shower schedule and aides fill out shower sheets when done.
During an interview on 01/21/24 at 11:48 A.M., Certified Nursing Assistant (CNA) B said residents should have two showers a week, and if they didn't, it was due to low staffing.
During an interview on 01/21/24 at 11:49 A.M., CNA C said they did have a shower aide that performed showers, but due to low staffing, there isn't one now, and if a resident refuses a shower, CNAs fill out a shower sheet, mark refused, and tell the charge nurse.
During an interview on 01/21/24 at 12:30 P.M., the Administrator said the prior shower aide did not work out, and a new shower aide will be assigned to ensure residents will receive showers twice per week.
CMP #MO232039
Aug 2023
3 deficiencies
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 interview and record review, the facility failed to follow the resident's risk assessment dated [DATE] to ensure staff ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the resident's risk assessment dated [DATE] to ensure staff utilized safe transfer techniques for one resident (Resident #5) when staff failed to transfer the resident via mechanical lift. The resident sustained a right mid shaft femur fracture (the long, straight part of the thighbone). The facility census was 39.
Review of the facility's policy titled, Transfer Activities, not dated, showed:
- The purpose is to transfer the resident from bed to chair safely;
- Gather equipment, mechanical lift, if necessary.
1. Review of Resident #5's medical chart showed:
- An admission date of 07/19/23;
- Diagnoses of thyroid disorder, malnutrition (lack of proper nutrition), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and act);
- Cognitively impaired;
- Received hospice services;
- Weight of 67 pounds (lbs.).
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 07/26/23, showed:
- Cognitively impaired;
- Total dependence of one staff for bed mobility, dressing, personal hygiene and bathing;
- Total dependence of two staff for transfers and toilet use;
- Always incontinent of bowel and bladder.
Review of the resident's Lift Assessment, dated 08/09/23, showed:
- Weight less than 99 lbs.;
- Able to bear partial weight, extreme weakness;
- Impaired sensory perception;
- Required a minimum of two staff to lift/transfer;
- Transfer the resident via mechanical lift.
Review of the resident's care plan, last revised 08/22/23, showed:
- The resident required assist of staff with activities of daily living (ADL's), incontinent care and transfers;
- Required a minimum of two staff to lift/transfer, dated 08/22/23;
- Did not address how to transfer the resident.
Review of the resident's hospital records, dated 8/24/23, showed:
- The resident presented to the emergency room with an extensive right thigh deformity with bone tenting (bone protruding out to the skin) in two places;
- The resident sustained a horrific closed right mid shaft femur fracture;
- It was reported the staff at the facility turned him/her and caused the thigh to snap.
- The resident was severely frail.
- Orthopedic surgeon consulted and only recommended traction (the action of pulling of on part of the body).
During an interview on 08/29/23 at 9:30 A.M., the Director of Nursing (DON) said the Certified Nurse Aide (CNA) D and G put the resident to bed after breakfast. The hospice staff showed up to care for the resident and at 9:45 A.M., at the request of the hospice nurse, the DON gave the resident a dose of Tylenol pain medication. At 10:00 A.M., the hospice nurse notified her of the resident's leg being abnormal. She went and assessed the resident's leg and the right knee was inverted inward and with the bone pushed against the skin of the right lateral (most outer side) thigh. The resident complained of pain. The physician was called and gave a new order to send the resident to the emergency room.
During a phone interview on 08/29/23 at 2:03 P.M., CNA D said the the resident made a face when the wheelchair was bumped after he/she propelled the chair back to the room. The resident complained of pain. CNA D said the mechanical lift pad was not positioned under the resident safely, so CNA D and CNA G used a bed/incontinent pad to transfer the resident from the chair to the bed by holding on to opposite sides of the pad and lifted the resident from the chair to the bed.
During an interview on 08/29/23 at 3:07 P.M., the DON said CNA D and CNA G told her they transferred the resident with a bed/incontinent pad from the chair to the bed.
During an interview on 08/29/23 at 3:43 P.M., the Physician said if the resident's medical record showed they should be transferred with a mechanical lift, then that was what he/she would expect.
During an interview on 08/29/23 at 3:56 P.M., CNA E said if he/she wasn't sure how to transfer a resident, then he/she should look at the care plan. If it's not on the care plan, then he/she would ask the charge nurse. He/She would absolutely never use an incontinent pad/bed pad to transfer a resident. If the resident's medical record showed a gait belt transfer, then the gait belt should be used, and if it showed a mechanical lift, then that was what should be used.
During an interview on 08/29/23 at 4:00 P.M., Nurse Aide (NA) F said he/she would look at the care plan, if not there, then he/she would ask the charge nurse, then the DON. He/she said the facility had ordered a smaller mechanical lift pad for the resident.
During an interview on 08/29/23 at 4:35 P.M., the Administrator said there had been an in-service completed 08/02/23 regarding the correct way to transfer this resident. The staff knew they should be transferring the resident by the mechanical lift. The two CNA's that improperly transferred the resident had been re-educated.
During a phone interview on 08/31/23 at 10:32 A.M., CNA H said on the early morning of 08/24/23, he/she transferred the resident by him/herself with the mechanical lift. The resident did not have any abnormalities of any kind at that time and no facial grimace or anything.
During a phone interview on 08/31/23 at 10:58 A.M., CNA G said he/she assisted CNA D in transferring the resident with the bed/incontinent pad due to the mechanical lift pad not being correctly positioned under the resident. He/She was never told or inserviced on how to transfer the resident.
Complaint #MO223432 and MO223559
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
Based on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when Certified Nurse Assistant (CNA) C slapped Resident #1's hand...
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Based on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when Certified Nurse Assistant (CNA) C slapped Resident #1's hand in an effort to make him/her release items that did not belong to the resident. The facility census was 39.
Review of the facility's policy titled, Abuse Prevention, not dated, showed:
- The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms;
- Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone;
- Ensure reporting of crimes against a resident or individual receiving care from the facility occurring in nursing homes within prescribed timeframes to the appropriate entities;
- Ensure that all covered individuals, such as the owner, operator, employee, manager, agent or contractor report reasonable suspicion of crimes;
- Provide annual notification for covered individuals of these reporting requirements;
- Post a conspicuous notice of employee rights, including the right to file a complaint;
- Assure that any covered individual who makes a report, or is in the process of making a
report, is not retaliated against;
-The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: thoroughly investigate the alleged violation; prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and take appropriate corrective action, as a result of investigation findings;
- Abuse: is defined at §483.5 as the willful infliction of injury, unreasonable confinement,
intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm;
- Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again;
- Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking;
- It is the policy of this facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties;
- An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator;
- The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements.
1. Review of Resident #1's medical record showed:
- An admission date of 01/22/20;
- Diagnoses of anxiety (a feeling of fear, dread, and uneasiness), major depressive disorder (a mental health disorder characterized by persistently depressed mood), unspecified dementia (dementia without a specific diagnosis, multiple types of mental and physical conditions present at once), psychotic disturbances (loss of contact with reality), and Alzheimer's disease (progressive decline in episodic memory, with variable involvement of other cognitive areas)
Review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 05/20/23, showed:
- Severely cognitively impaired;
- Fluctuation of inattention;
- Fluctuation of disorganized thinking;
- Trouble concentrating nearly every day;
- Wanders daily.
Review of the facility's investigation of the incident, dated 08/21/23, showed:
- At 5:24 P.M., on 08/20/23, the Administrator was contacted by Registered Nurse (RN) B;
- RN B said CNA A witnessed CNA C slap the top of Resident #1's hand after CNA C grabbed the resident's hand to pull it away from taking someone else's coloring page;
- There were other residents and their family members present;
- It was reported CNA C said he/she didn't smack the resident's hand hard;
- CNA C was removed form the facility and sent home;
- Resident #1 had no injuries and or behavior changes;
- CNA C was terminated.
Observation of the resident on 08/29/23 at 12:00 P.M., showed no bruising or injuries on the resident's hands.
During an interview on 08/29/23 at 9:05 A.M., the Administrator said CNA C was witnessed slapping the hand of Resident #1. CNA A witnessed the incident and reported it. Witness A was visiting another resident and witnessed it, as well. The incident happened on Sunday, August 20, 2023, and CNA C was on vacation the following Monday through Friday, August 21 - 25, 2023. CNA C was contacted about the incident after he/she returned from vacation. CNA C tried to say he/she put her hand around the resident's wrist and it may have appeared that she slapped her hand. The Administrator explained to CNA C that Witness A also saw him/her slap Resident #1's hand. CNA C did not say anything further and had no excuse as to why CNA A and Witness A were saying they witnessed him/her slap the resident on the hand. CNA C was then terminated.
During an interview on 08/29/23 at 12:20 P.M., CNA A said he/she witnessed CNA C slap Resident #1 on the hand hard enough to make a popping noise. This was the first time he/she had witnessed CNA C slap a resident.
During a phone interview on 08/29/23 at 12:51 P.M., CNA C said the incident happened on 08/20/21 at supper time. Resident #1 kept getting into other people's things. CNA C said his/her fingers accidentally went on top of the resident's hand and someone was claiming he/she slapped the resident's hand. CNA C said he/she put his/her fingers on top of the resident's hand, kind of like when you pet an animal, he/she lightly put her fingers on the resident's hand. CNA C said he/she didn't pat the resident's hand, but just set his/her fingers on top of them. CNA C later said he/she lightly patted the resident's hand. CNA C said that was how he/she normally handled Resident #1 when he/she got into things that he/she was not supposed to. He/She would try to move the resident away from areas the resident shouldn't be in. He/She had worked at the facility for almost 14 years.
During a phone interview on 08/30/23 at 12:45 P.M., Witness A said on Sunday, August 20, 2023, he/she was visiting a resident in the facility. Resident #1 came to the other residents' table and reached for items that were not his/hers. CNA C smacked the resident's hand, like how someone might smack a child's hand if they were grabbing something they were not supposed to. CNA C then forcibly moved the resident away from the other residents' table. CNA C told Witness A he/she probably shouldn't have smacked Resident #1's hand like that, but the resident had been horrible all day.
Complaint #MO223256
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADL's) when the residents did not receive a minimum of two showers per week for three residents (Resident #1, #2, and #5) out of three sampled residents. The facility census was 39.
The facility did not provide a policy related to shower frequency.
Review of the shower list showed:
- Resident #1 scheduled for showers two times weekly;
- Resident #2 scheduled for showers two times weekly;
- Resident #5 scheduled for showers two times weekly.
1. Review of Resident 1's medical record showed:
- An admission date of 01/22/20;
- Diagnoses of hypertension (high blood pressure), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety disorder (severe ongoing anxiety that interferes with daily activities).
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility), dated 05/20/23 showed:
- Cognitive status severely impaired;
- Extensive assistance of one staff for dressing and personal hygiene;
- Total dependence of one staff for bathing;
- Received hospice (a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness and their caregiver) services.
Review of the resident's shower sheets, dated July 2023 through August 29, 2023, showed no documentation for showers on 08/22/23 and 08/25/23 with two out of seven opportunities missed.
Review of the resident's care plan, last revision date of 08/24/23, did not address showers or bathing.
Observation on 08/28/23 at 12:10 P.M., showed the resident sat in his/her wheelchair with his/her hair unkempt and dirty.
Review of Resident 2's medical record showed:
- An admission date of 05/17/23;
- Diagnoses of diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), anxiety disorder, and chronic obstructive pulmonary disease (COPD) (a condition involving constriction of the airways and difficulty or discomfort in breathing).
Review of the resident's quarterly MDS, dated [DATE], showed:
- Severely impaired cognition;
- Extensive assistance of one staff for dressing;
- Total dependence of one staff for personal hygiene and bathing.
Review of the resident's shower sheets, dated July 2023 and through August 29, 2023, showed no documentation for showers on 08/08/23, 08/11/23, 08/15/23, 08/18/23, 08/22/23 and 08/25/23 with six out of seven opportunities missed.
Review of the resident's care plan, last revision date of 08/18/23, did not address showers or bathing.
Observation on 08/28/23 at 9:50 A.M., showed the resident lay in bed with his/her hair unkempt.
During an interview on 08/28/23 at 12:50 P.M., the resident said he/she knew the facility was low on help. He/She took a shower when the staff could give it to him/her.
Review of Resident 5's medical record showed:
- An admission date of 08/01/23;
- Diagnoses of anxiety and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act).
Review of the resident's admission MDS, dated [DATE], showed:
- Moderately impaired cognition;
- Extensive assistance of two staff for dressing and personal hygiene;
- Total dependence of two staff for bathing.
Review of the resident's care plan, last revision date of 08/15/23, did not address showers or bathing.
Review of the resident's shower sheets, dated August 2023 showed:
- No documentation for showers on 08/08/23, 08/11/23, 08/15/23, 08/18/23, and 08/25/23 with five out of seven opportunities missed.
Observation on 08/28/23 at 10:45 A.M., showed the resident lay in bed with his/her hair unkempt.
During an interview on 08/28/23 at 11:00 A.M., Certified Nurse Aide (CNA) D said there was not a shower aide today. There were only the two CNA's working off the unit, and one CNA on the unit. If someone came in early on the next shift, then one of the staff could do showers.
During an interview on 08/28/23 at 11:03 A.M., Nurse Aide (NA) F said if an an extra aide came in today, then one of the CNA's would do the showers. If not, showers would not get done today.
During an interview on 08/28/23 at 11:23 A.M., the Director of Nursing (DON) said the facility did not do any showers for Resident #1 because hospice gave all of his/her showers. She said she knew Resident #2 had one last week due to she had been on the hall when staff was finishing up with the shower. However, she did not know anything about Resident #5 having a shower. She provided all the shower sheets she had, but maybe there was some missing sheets.
During an interview on 08/28/23 at 12:08 P.M., the Administrator said the facility lost their shower aide last week. Typically showers could be done on days or evenings. The facility did not have a shower schedule for each resident but provided a shower list by the resident room numbers.
Complaint #MO223605
Aug 2023
19 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
Based on observation, interview and record review, the facility failed to maintain infection control practices when staff and a resident touched cups and silverware where residents put their mouth wit...
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Based on observation, interview and record review, the facility failed to maintain infection control practices when staff and a resident touched cups and silverware where residents put their mouth without performing hand hygiene. The facility failed to perform hand hygiene between glove changes during incontinent care for three residents (Residents #3, #7 and #35) of six sampled residents. The facility failed to perform hand hygiene between residents when administering medications for three residents (Resident #8, #18, and #28) out of seven sampled residents. The facility failed in the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) screening of five residents (Resident #4, #7, #10, #36, and #40) out of five sampled residents. The facility failed to implement a risk management process specific to Legionella disease (a serious type of pneumonia caused by Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility's census was 40.
Review of the facility's policy titled, Glove Use, dated 5/2015 showed:
- This is to insure safe and proper food handling during food preparation and services;
- The food code states that food items should not be handled with bare hands;
- When serving, preference is not to use gloves unless only one task is being performed;
- Hand washing per guidelines should occur between each task;
- Gloves should be worn if handling food is necessary;
- Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines;
- Hands should be washed before beginning each task, after disposing of trash or food, after handling dirty dishes, after picking up anything from the floor, when changing tasks and any other time deemed necessary.
Observations on 08/01/23 lunch meal showed:
- At 11:50 A.M., Certified Nurse Assistant (CNA) D held two cups by the top to pour liquid into them with his/her bare hands;
- At 11:52 A.M., Resident #30 carried four cups by the top from the drink cart to other residents with his/her bare hands;
- At 11:56 A.M., CNA D carried four cups by the top from the drink cart with his/her bare hands to the tables for two residents;
- At 12:11 P.M., CNA C pushed Resident #14's wheelchair to the dining room. CNA C picked up a spoon by the mouth part for another resident and put it into a potato. CNA C then put on gloves to cut up the potato;
- At 12:39 P.M., the Dietary Manager delivered hall trays with the residents' meals to four resident rooms on the 300 Hallway and did not sanitize hands his/her hands between each resident's meal tray delivery.
During an interview on 08/04/23 at 5:27 P.M., the Administrator said staff should sanitize their hands before they enter a resident's room with a hall tray. Staff should not move to the next resident's room without sanitizing their hands.
During an interview on 08/03/23 at 9:14 A.M., the Dietary Manager said when staff serve hall trays to the residents' rooms, their hands should be washed or sanitized before moving on to the next resident room.
Review of the facility's policy titled, Perineal Care, undated, showed:
- Gather necessary equipment;
- Put on disposable gloves;
- Provide pericare;
- Remove gloves and wash hands;
- Replace blanket and spread;
- Raise side rail and turn bed to previous position with call light.
Review of the facility's policy titled, Handwashing, revised 5/2015, showed:
- If using gloves, remove gloves;
- Roll down paper towels, turn on water, wet hands, lather, wash hands/forearms, rinse;
- Turn off water with paper towel;
- Did not address sanitizing hands between changing gloves.
2. Observation of pericare provided for Resident #3 on 08/02/23 at 9:29 A.M., showed:
- CNA C and CNA F put on clean gloves;
- CNA C and CNA F removed the resident's urine saturated hoyer lift sling, pants and brief;
- CNA F cleansed the resident's buttocks;
- CNA F changed gloves, but did not wash/sanitize his/her hands prior to putting on the clean gloves;
- CNA F put a new brief down under the resident and rolled the resident to assist CNA C to get the brief completely under the resident;
- CNA C cleansed the resident's peri area;
- CNA C changed gloves but did not wash/sanitize his/her hands prior to putting on the clean gloves.
Observation of incontinent care provided for Resident #7 on 08/02/23 at 2:07 P.M., showed:
- CNA J and Nurse Assistant (NA) K put on gloves;
- CNA J and NA K to transferred the resident to the toilet from the wheelchair via a sit to stand lift (a medical device that assists individuals with limited mobility in standing up from a seated position);
- CNA J stood the resident up from the toilet with the sit to stand lift;
- CNA J performed incontinent care;
- CNA J did not change gloves nor wash/sanitize his/her hands after incontinent care was provided;
- CNA J touched the sit to stand lift with the soiled gloves to transfer the resident back into his/her wheelchair;
- CNA J touched the sit to stand sling with the soiled gloves around the the resident's chest.
Observation of incontinent care provided for Resident #35 on 08/02/23 at 2:07 P.M., showed
- CNA J and NA K put on clean gloves;
- CNA J and NA K stood the resident up with the sit to stand lift;
- CNA J provided incontinent care to the resident;
- CNA J did not change gloves nor wash/sanitize his/her hands;
- CNA J touched the sit to stand lift with the soiled gloves to transfer the resident back into his/her wheelchair;
- CNA J touched the sit to stand sling with the soiled gloves around the the resident's chest.
3. Observation of the medication pass on 08/03/23, showed:
- At 8:20 A.M., Registered Nurse (RN) A did not wash/sanitize his/her hands prior to or after the medication administration to Resident #28;
- At 8:23 A.M., Registered Nurse (RN) A did not wash/sanitize his/her hands prior to or after the medication administration to Resident #18;
- At 8:27 A.M., Registered Nurse (RN) A did not wash/sanitize his/her hands prior to the medication administration to Resident #8.
During an interview on 08/04/23 at 2:57 P.M., the Director of Nursing (DON) said staff should wash or sanitize their hands prior to administering medication, and between every resident.
Review of the facility's policy titled, Tuberculosis Control Program, dated May 2015, showed:
- Purpose is to determine if the resident has been exposed to TB;
- After administering the test, measure the area of induration (hardening, thickening of tissues) at 48 and 72 hours;
- If a positive reaction occurs, notify the physician and carry out additional orders;
- If a two step TB testing procedure has been approved by the facility's Infection Control Committee, repeat this process within the time period specified in guidelines for when test results are negative;
- Repeat testing at regular intervals as determined by the facility's infection control guidelines.
4. Review of Resident #4's medical record showed:
- An admission date of 6/7/19;
- No TB screening documentation for 2022 or 2023.
Review of Resident #7's medical record showed:
- An admission date of 06/05/23;
- No documentation of the first or second step TB tests.
Review of Resident #10's medical record showed:
- An admission date of 02/01/21;
- No TB screening documentation for 2022 or 2023.
Record review of Resident #36's medical record showed:
- An admission date of 12/20/22;
- No documentation of the first or second step TB tests.
Review of Resident #40's medical record showed:
- An admission date of 05/04/23;
- No documentation of the first or second step TB tests.
The facility did not provide a Legionella Maintenance/Surveillance policy.
During an interview on 08/04/23 at 8:35 A.M., the Maintenance Supervisor said he/she did not know about any measures in place to prevent the growth of Legionella, documentation related to it, or any routine checks being performed. He/She said the local health department probably knows about that.
During an interview on 08/04/23 at 8:45 A.M., the Administrator said the facility did not have a Legionella policy and as far as she knew, had no measures in place to prevent the growth of Legionella, documentation related to it, or any routine checks.
Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification letter dated 6/2/17, showed the facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the Center for Disease Control and Prevention (CDC) toolkit. The toolkit should contain the following: text and flow diagrams, identify areas where Legionella could grow and spread, that the team has conducted a water program review at least annually, as stated. The annual review should: 1) be implemented; 2) record findings and updates; 3) record participants; and 4) be submitted to the Executive Director.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently document residents' code status with Do Not Resuscitat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently document residents' code status with Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for two residents (Residents #7 and #40) out of 12 sampled residents. The facility census was 40.
Record review of the facility's policy on Advance Directives, undated, showed:
- Upon admission of a resident to the facility, the social service designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical surgical treatment and the right to formulate an advance directive.
- The social service designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directive.
- Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab.
1. Review of Resident 7's medical record showed:
- An admission date of [DATE];
- The facesheet showed Do Not Resuscitate (DNR) (does not want cardiopulmonary resuscitation) (CPR) (an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) code status order;
- The Physician's Order Sheet (POS), dated [DATE], indicated the resident a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status dated [DATE];
- DNR signed on [DATE] by physician in resident records;
- The revised care plan dated [DATE] did not address the resident's code status;
- The Advance Directive binder located at the nurse's station did not have any information for this resident.
2. Review of Resident 40's medical record showed:
- An admission date of [DATE];
- The facesheet showed full code status;
- The POS, dated [DATE], did not address the resident's code status;
- The revised care plan, dated [DATE], did not address the resident's code status;
- The Advance Directive binder located at the nurse's station did not have any information for this resident.
During an interview on [DATE] at 9:30 A.M., Register Nurse (RN) A said he/she could not find any information about Resident #7 in the Advanced Directive binder. That if someone codes they immediately go to this binder to look for code status.
During an interview on [DATE] at 10:00 A.M., the Director of Nursing (DON) said she would expect a resident's code status to be documented consistently throughout the resident's medical record.
During an interview on [DATE] at 10:15 A.M., the Administrator said she would expect a resident's code status be documented consistently throughout the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
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 complete ongoing re-evaluations for the continued need...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete ongoing re-evaluations for the continued need of a restraint (a device that limits a person's movement) for two residents (Residents #7 and #35) out of two sampled residents. The facility census was 40.
Record review of the facility's policy titled, Use of Restraints, undated, showed:
- Restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls;
- Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body;
- The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it, given the resident's physical condition, and this restricts his/her typical ability to change position or place, the device is considered a restraint;
- Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need. The assessment shall be used to determine possible underlying causes and to determine if there are less restrictive interventions that may improve the symptoms;
- Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use;
- Documentation regarding the use of restraints shall include: the episode leading to the use, the resident's medical symptoms that warranted the use, how the use benefits the resident, the type of restraint used and length.
1. Review of Resident #7's medical record showed:
- An admission date of 06/05/23;
- Diagnoses of a history of falling, muscle weakness, difficulty in walking, Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), and spinal stenosis (a narrowing of the spinal canal in the lower part of the back);
- Required assistance of one to two staff for toileting;
- No documentation of a physical restraint assessment.
Review of the resident's admission Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff), dated 06/12/23, showed no alarm used for the resident.
Review of the resident's care plan, revised on 07/30/23, showed:
- The resident had falls;
- An intervention of a wheelchair alarm while up in the wheelchair, dated 06/19/23.
Observations of the resident showed on 08/01/23 at 10:59 A.M., on 08/02/23 at 8:46 A.M., on 08/03/23 at 8:10 A.M., and on 08/04/23 at 8:15 A.M., showed:
- The the resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to the back of the resident's shirt in the common area;
- The resident was unable to remove the chair alarm.
2. Review of Resident #35's medical record showed:
- An admission date of 10/28/22;
- Diagnoses of vascular dementia (changes to memory, thinking and behavior resulting from conditions that affect the blood vessels in the brain), arthritis, repeated falls, abnormal posture, history of falls, Parkinson's disease, and muscle weakness;
- Required assistance of one staff for toileting;
- No documentation of a physical restraint assessment.
Review of the resident's quarterly MDS, dated [DATE], showed no alarm used for the resident.
Review of the resident's care plan, reviewed on 05/31/23, showed:
- The resident had falls;
- An intervention of an evaluation for the bed/chair alarms, dated 11/15/22.
Observations of the resident on 08/01/23 at 10:35 A.M., and on 08/02/23 at 8:46 A.M., showed:
- The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to the back of the resident's shirt in the common area;
- The resident was unable to remove the chair alarm.
Observation of the resident on 08/02/23 at 2:06 P.M., showed:
- The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to the back of the resident's shirt in the hallway;
- The resident was unable to remove the chair alarm.
Observation of the resident on 08/03/23 at 4:45 P.M., showed:
- The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to the back of the resident's shirt at a table in the dining room;
- The resident was unable to remove the chair alarm;
- The resident leaned forward and detached the chair alarm from the wheelchair which caused it to alarm;
- The resident startled and looked around until staff responded to the alarm.
Observation of the resident on 08/04/23 at 8:17 A.M., showed:
- The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to the back of the resident's shirt at a table in the dining room;
- The resident was unable to remove the chair alarm.
During an interview on 08/04/23 at 10:05 A.M., the Director of Nursing said residents should have assessments completed in regards to chair alarms. Both residents were fall risks and the purpose was to let staff know that they needed assistance.
During an interview on 08/04/23 at 10:10 A.M., the Administrator said residents should have assessments completed in regards to chair alarms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments, a federally mandated assessment to be completed by the facility staff, for two residents (Residents #9 and #35) out of 12 sampled residents. The facility census was 40.
The facility did not provide an accuracy of the MDS assessment policy.
1. Review of Resident #9's annual MDS, dated [DATE], showed:
- The resident did not receive antidepressant (a medication used to treat depression) medication;
- The resident received antipsychotic (medication used to treat psychotic disorders) medication seven out of seven days;
- The resident required total assistance of one staff for transfers.
Review of the resident's Physician Order Sheet (POS), dated August 2023, showed:
- A diagnosis of depression (a constant feeling of sadness and loss of interest);
- An order, dated 07/19/23, for sertraline (an antidepressant) 25 milligram (mg) one tablet by mouth once a day at 6:00 P.M.;
- No order for antipsychotic medication.
Review of the resident's Lift Assessment, dated 07/19/23, showed the resident required a minimum of three staff or a mechanical lift (devices used to assist with transfers) for a lift/transfer.
During an interview on 08/03/23 at 2:27 P.M., the Director of Nursing said the resident required a two person assist with a gait belt for transfers and the MDS should reflect the resident's condition and medications accurately.
2. Review of Resident #35's quarterly MDS, dated [DATE], showed the resident did not receive restraints or alarms.
Review of the resident's care plan, last updated 05/31/23, showed:
- The resident had falls;
- An intervention to be evaluated for bed/chair alarms, dated 11/15/22.
Observations of the resident showed:
- On 08/01/23 at 10:35 A.M., the resident sat in a wheelchair in the common area with a chair alarm on;
- On 08/02/23 at 8:46 A.M., the resident sat in a wheelchair in the common area with a chair alarm on;
- On 08/02/23 at 2:06 P.M., the resident sat in a wheelchair in the hallway with a chair alarm on;
- On 08/03/23 at 4:45 P.M., the resident sat in a wheelchair with a chair alarm on at a table in the dining room, the resident leaned forward and pulled the chair alarm which caused it to alarm;
- On 08/04/23 at 8:17 A.M., the resident sat in a wheelchair with a chair alarm on at a table in the dining room.
During an interview on 08/02/23 at 11:27 P.M., the Director of Nursing said she would expect the MDS to accurately reflect the resident's complete condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on interview and closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs and involved the resident and/or the resident's leg...
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Based on interview and closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs and involved the resident and/or the resident's legal guardian and the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) in developing a discharge plan for one resident (Resident #41) out of one sampled discharged resident. The facility census was 40.
Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed:
- Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident;
- Complete a discharge summary and post-discharge plan of care form, include the list of medications, the post-discharge care, the person responsible for the care to sign the discharge summary and the post-discharge care form, give a copy to the resident and/or representative, and place in the medical record.
DEFINITIONS §483.21(c)(1) states: Discharge planning begins at admission and is based on the resident's assessment and goals for care, desire to be discharged , and the resident's capacity for discharge. It also includes identifying changes in the resident's condition, which may impact the discharge plan, warranting revisions to interventions. A well-executed discharge planning process, without avoidable complications, maximizes each resident's potential to improve, to the extent possible, based on his or her clinical condition. An inadequate discharge planning process may complicate the resident's recovery, lead to admission to a hospital, or even result in the resident's death.
1. Review of Resident #41's closed medical record showed:
- admission date of 07/17/23;
- Diagnoses of atrial fibrillation (heart dysrhythmia), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), kidney disease, presence of a cardiac pacemaker (a medical device that generates electrical impulses to the heart that cause it to pump blood), hypertension (HTN) (high blood pressure), anxiety disorder (persistent worry and fear about everyday situations), and chronic obstructive pulmonary disease (COPD) (an inflammatory lung disease that causes obstructed airflow from the lungs);
- Legal guardian;
- The Managed Care Discharge to Long Term Care Summary, dated 07/25/23, showed the planning and recommendations for post-discharge care section not completed and the summary of the recapitulation not completed;
- No documentation that addressed the resident's preference and potential for a future discharge;
- No documentation of an assessment for the resident's continued care needs;
- No documentation of an IDT discharge plan of care completed for the resident and provided to the resident/or the resident's legal guardian.
During an interview on 08/04/23 at 10:10 A.M., the Administrator said the facility didn't really have any notice about the discharge. The resident just one day said he/she wanted to move out because not wanting to be in the room with the roommate and there was no other room available. There was no documentation or forms and the one form was not fully completed. The discharge nurse should fill out the form and IDT should assist the resident and/or the representative in developing a discharge plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #41) out of one sampled discharged resident. The facility cens...
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Based on interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #41) out of one sampled discharged resident. The facility census was 40.
Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed:
- Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident;
- Complete a discharge summary and post-discharge plan of care form, include the list of medications, post-discharge care, the person responsible for the care to sign the discharge summary and the post-discharge care form, give a copy to the resident and/or representative, and place in the medical record.
1. Review of Resident #41's closed medical record showed:
- The resident discharged on 07/25/23;
- The Managed Care Discharge to Long Term Care Summary, dated 07/25/23, showed the planning and recommendations for post-discharge section not completed, and the recapitulation section not completed;
- No documentation of a comprehensive discharge summary.
During an interview on 08/04/23 at 10:10 A.M., the Administrator said the facility or nursing department should complete a comprehensive discharge summary, including a recapitulation of a resident's stay, prior to the discharge of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #4) out of 12 sampled residents. The facility census was 40.
The facilit...
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Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #4) out of 12 sampled residents. The facility census was 40.
The facility did not provide a policy related to following physician's orders.
1. Review of Resident #4's Physicians Order Sheet (POS), dated August 2023, showed:
- Diagnoses of multiple sclerosis (a disease that results in nerve damage disrupting the communication between the brain and body), contracture (a condition of shortening or hardening of the muscles) of the left ankle, and contracture of right ankle;
- An order, dated 04/13/21 for Dynasplint (a stretching device that helps increase joint range of motion) braces to be worn eight hours a day while supine (on back with face and abdomen facing up) in bed;
- An order, dated 04/13/21, to monitor for skin breakdown when doffing (removing) the braces.
Review of the resident's medical record showed:
- No documentation of the application of the braces;
- No documentation of the monitoring of the skin on removal of the braces;
- No documentation of the resident refused to wear the braces.
Observations of the resident showed:
- On 08/01/23 at 10:14 A.M., a sign on the resident's closet door that said the resident was to wear foot braces while in bed;
- On 08/01/23 at 10:14 A.M., the resident lay in bed with no braces on his/her feet;
- On 08/02/23 at 10:26 A.M., the resident lay in bed with no braces on his/her feet;
- On 08/03/23 at 8:51 A.M., the resident lay in bed with no braces on his/her feet.
During an interview on 08/02/23 at 10:20 A.M., the resident said the braces were not on and they hadn't been for a month or more. He/She thought they were worn to help keep his ankles straight, and didn't know why they weren't on, they just hadn't been put on. Observation on 08/03/23 at 8:51 A.M., showed Registered Nurse (RN) A , looked in the room for the braces and was unable to find them.
During an interview on 08/03/23 at 8:51 A.M., RN A said he/she thought the resident was supposed to wear the braces when he/she was out of the bed and up in the chair. One pair of braces was found, but it was not the ones the resident was supposed to wear.
During an interview on 08/03/23 at 1:20 P.M., the Administrator said she was sure the resident was non-compliant with the foot braces, and they had been unable to find them. She would expect the use of the braces or the resident's non-compliance with wearing them to be documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident haza...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in two occupied resident room sinks (Residents #23 and #35), which put the residents at an increased risk of injuries from exposure to the hot water. The facility failed to assess three of three sampled residents who were identified as residents who smoke (Residents #4, #36 and #40) to ensure they were able to smoke safely. The facility also failed to ensure staff utilized safe transfer techniques for two of eight sampled residents (Residents #7 and #9). These practices had the potential to affect all the residents at the facility. The facility census was 40.
The facility did not provide a policy regarding water temperatures.
Review of the Burn Foundation website showed hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters:
- In one second at 156 degrees F;
- In two seconds at 149 degrees F;
- In five seconds at 140 degrees F;
- In 15 seconds at 133 degrees F;
- In one minute at 127 degrees F.
Review of the facility's policy titled, Smoking, undated, showed:
- The facility would provide direct supervision for residents classified as not responsible;
- Smoking privileges, restrictions and concerns shall be noted on the resident's care plan;
- The staff will review the status of a resident's smoking privileges periodically, and consult as needed the Director of Nursing (DON) and the attending physician.
1. Observation on 08/03/23 at 11:15 A.M., of the electrical room showed two hot water heaters with non-digital external thermometers for monitoring and setting temperatures. One was set at 125 degrees F and the other at 128 degrees F.
Observation on 08/04/23 at 8:32 A.M., of the water temperature taken at 30 and 60 seconds with a digital thermometer showed:
- room [ROOM NUMBER] water temperature recorded at 130.5 degrees F at the sink for 45 seconds and then slowly dropped to 127 degrees F for 60 seconds;
- room [ROOM NUMBER] water temperature recorded at 124 degrees F at the sink for 60 seconds;
- Both rooms were occupied by residents capable of using the sinks as needed.
Observation on 08/04/23 at 11:20 A.M., showed room [ROOM NUMBER]'s water temperature recorded at 130 to 134.2 degrees F for 45 seconds.
During an interview on 08/03/23 at 11:10 A.M., the Maintenance Director said he/she checked the water temperatures weekly by choosing a sample of 10 resident use areas. The Maintenance Director said he/she had recently been told he/she had not been using the correct kind of thermometer and verified his/her thermometer was not the digital foodservice kind. The Maintenance Director said there had been no complaints regarding the water temperatures to his/her knowledge. The Maintenance Director was not aware of any policies or procedures regarding testing hot water temperatures. The Maintenance Director said he/she would lower the temperatures on the water heaters immediately.
During an interview on 08/04/23 at 4:50 P.M., the Administrator said the water temperatures should be checked by maintenance regularly. She could not remember if water temperatures were to be checked weekly or monthly. She recently found out the Maintenance Director had been checking water temperatures with a regular thermometer, but the correct type of thermometer was going to be purchased and used going further.
2. The facility provided a list of residents who participate in smoking cigarettes, which included residents #4, #36 and #40.
Review of Resident #4's medical records showed:
- A Smoking assessment, dated 06/16/22, identified the resident a safe smoker;
- No other documentation of a re-assessment for smoking;
- No care plan with special interventions related to smoking cigarettes.
During an interview on 08/02/23 at 12:43 P.M., Resident #4 said he/she did smoke cigarettes at times, but had not in a few days. When he/she did smoke, staff was there and sometimes put an apron on him/her.
Review of Resident #36's medical records showed no documentation of a Smoking assessment.
Review of Resident #40's medical records showed no documentation of a Smoking assessment;
During an interview on 08/02/23 at 3:10 P.M., the Administrator said the residents that smoke should have a smoking assessment done to ensure safety for the residents. The assessments used to be done quarterly, but they were probably not even getting done now. The quarterly assessments should be located in the resident's medical record and should also be on the care plan. All residents were only allowed to smoke during staff chaperoned smoke breaks.
3. Review of Resident #7's medical record showed:
- An admission date of 06/05/23;
- Diagnoses included history of falling, muscle weakness, Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), spinal stenosis (a narrowing of the spinal canal in the lower part of the back); and dysphagia (difficulty speaking);
- The admission MDS, dated [DATE], showed the resident to be a limited assist of two staff for transfers;
- A Physical Therapy (PT) evaluation, dated 06/09/23, identified the resident required maximal assist with all transfers.
- No Lift Assessment;
- The resident's care plan, revised on 06/12/23 identified the resident required assistance of one to two staff for transfers and ambulation with a walker.
Observation on 08/02/23 at 1:46 P.M., showed:
- Certified Nursing Assistant (CNA) J and Nursing Assistant (NA) K assisted the resident from the wheelchair to the toilet and from the toilet back to the wheelchair via a sit to stand lift (assist mobility patients when they are unable to transition from a sitting position to a standing position on their own);
- The resident hung by the sling and arms from the sit to stand with the sling moved under axillary area and knees bent;
- The resident was then pushed between the wheelchair and the toilet and from the toilet back to the wheelchair;
- The resident hung by the sling and arms from the sit to stand lift while the sling moved under the resident's axillary area and with knees bent while being pushed.
During an interview on 08/02/23 at 2:50 P.M., CNA J said Resident #7 is a difficult transfer so he/she used the sit to stand lift with him/her. CNA J said the resident does not stand, but hangs in the sling of the sit to stand lift. CNA J did not know what the care plan said or if the PT had given any recommendations for transferring the resident.
During an interview on 08/03/23 at 9:30 A.M., Physical Therapist M said Resident #7 was not to be transferred with a sit to stand lift. The resident would not tolerate it well. PT M said staff could transfer Resident #7 with a gait belt and with moderate assistance of one to two staff.
During an interview on 08/04/23 at 5:00 P.M., the DON said Resident #7 was a gait belt assist of two for transfers. She said she had recently heard Resident #7 yell when he/she was transferred with a sit to stand lift. The DON did not know staff continue to used the sit to stand lift for transfers of Resident #7. The DON has not observed staff transfer Resident #7 recently.
Review of Resident #9's medical record showed:
- An admission date of 07/19/23;
- Continue hospice services;
- An admission weight of 67 pounds;
Review of the resident's baseline care plan, dated 07/19/23, showed:
- Assist of one for bed mobility;
- Assist of one for transfers;
- Assist of two for walking;
- Required a manual wheelchair.
Review of the resident's comprehensive care plan, dated 07/26/23, showed the care plan did not address transfers or mobility concerns with individualized interventions.
Review of the resident's Lift Assessment, dated 07/19/23, showed a minimum of three staff or mechanical lift for lift/transfer.
Observation and interview on 08/03/23 at 04:26 P.M., showed:
- The resident sat in the Geri (a large padded chair designed to help persons with limited mobility) chair in his/her room;
- NA G, CNA H and CNA I went into the resident's room to transfer the resident to bed;
- CNA I said there should be a Hoyer pad under the resident. In normal circumstances, a Hoyer lift was always used to transfer a resident from a Geri-chair. He/She had not transferred this resident before;
- None of the staff present sought out a Hoyer lift pad, or spoke with a charge nurse;
- CNA I placed one arm under the resident's right leg and one arm under the resident's right arm, NA G placed one arm under the resident's left leg and one arm under the resident's left arm, and lifted him/her from the Geri-chair;
- CNA H pulled the Geri-chair out from under the resident;
- NA G and CNA I lay the resident on the bed.
During an interview on 08/03/23 at 2:27 P.M., the DON said Resident #9 required a two person assist with a gait belt for transfers.
During an interview on 08/03/23 at 2:29 P.M., Registered Nurse (RN) A said his/her understanding was that Resident #9 required a Hoyer (an assistive device used to lift and transfer residents from one surface to another) lift for transfers. RN A did not know exactly what type of transfer Resident #9 was care planned for. RN A said he/she had not observed staff transfer Resident #9 recently.
During an interview on 08/03/23 at 2:35 P.M., NA G said he/she just manually picked the resident up to transfer him/her. NA G said he/she was still pretty new, but that is how the other staff have shown him/her to do it since her start date.
During an interview on 08/03/23 at 2:37 P.M., CNA H said he/she had never transferred the resident.
During an interview on 08/03/23 at 5:25 P.M., the Administrator said the facility did not have a small Hoyer pad for Resident #9, but was trying to get one. She would not expect a resident to be manually lifted. The Administrator did not know of a safe alternative way to transfer the resident. The Administrator did not know when the appropriately sized Hoyer lift pad would be available for the resident.
During an interview on 08/04/23 09:53 A.M. the DON said the resident was transferred this morning with a gait belt and a two person assist. The resident did not bear any weight and was pretty much a manual transfer.
During an interview on 08/04/23 at 4:50 P.M., the Administrator said when the transfer needs are put in the care plan there is a place that should be marked on the care plan, it transfers to the resident profile and the CNA's can see it on the system on the wall out on the hall. The Administrator said she would expect staff to transfer each resident as safely as possible.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #3) out of seven sampled...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #3) out of seven sampled residents who were incontinent of bowel and bladder received appropriate treatment and services after an incontinent episode. One resident was left without personal care for over six hours, resulting in the resident's brief being saturated with urine. The census was 40.
The facility did not provide a policy.
1. Review of Resident #3's Significant Change MDS, dated [DATE] showed:
- Transfer and bed mobility to be total dependant with assist of two plus staff;
- Toilet use to not have occurred;
- Personal hygiene to be total dependant with assist of one staff;
- Totally incontinent of bowel and bladder;
- At risk of pressure ulcer development with intervention of a pressure reducing cushion for bed/chair;
- Stage one pressure ulcer.
Review of the resident's current care plan, date 07/21/23, showed:
- Staff to assist with ADLs, incontinent care, and transfers with use of hoyer lift;
- Staff to assist the resident with toileting every two hours as needed;
- Staff to toilet the resident before meals, at bedtime and as needed.
Review of the resident's medical record showed:
- Diagnoses of Alzheimer's disease (progressive mental deterioration), intellectual disabilities, bipolar disease (a mental disorder that causes unusual shifts in mood), and dysphagia (speech impairment);
- Severely cognitively impaired;
- Totally dependent on staff for toileting.
-Record review of the facility assignment sheets showed on 08/03/23 CNA D as the only assigned staff to the secured locked unit for the day shift.
Observation on 08/03/23 at 8:28 A.M., showed Resident #3 resided on the secured locked unit and sat in a wheelchair in his/her room with the door closed and grunted loudly. Continuous observation showed at 9:23 A.M., the resident sat in a wheelchair in his/her room with the door closed and grunted loudly. At 09:44 A.M., the resident sat in a wheelchair in his/her room with the door closed. The resident grunted loudly and occasionally hit the wheelchair with his/ her hands. At 9:59 A.M., the resident continued to loudly grunt from his/her room with the door closed. At 10:01 A.M., CNA D went into the resident's room and told the resident to stop being loud and exited at 10:02 A.M. At 1:26 P.M., the resident sat in a wheelchair in his/her room and grunted loudly with the door closed. At 1:28 P.M., the CNA exited the hall to ask for assistance with transferring Resident #3. At 1:39 P.M., CNA D went into the resident's room and told him/her to be quiet. At 3:05 P.M., CNA D and CNA F transferred the resident from the wheelchair to the bed via a hoyer lift and incontinent care was provided to the resident. The resident's incontinent brief, pants, and the hoyer pad were saturated with urine. Continuous observations showed CNA D as the only staff providing care for the unit which consisted of 12 residents.
During an interview on 08/03/23 at 10:20 A.M., CNA D said he/she had not checked on or changed Resident #3 since his/her shift started at 6:00 A.M. Resident #3 had not been checked today at all. Resident #3 would be transferred to his/her bed and checked for incontinence after lunch sometime.
During an interview on 08/03/23 at 1:50 P.M., CNA D said when there are two aides assigned to the unit, then they check Resident #3 every two hours, but recently there was only one aide assigned to the unit. He/she had not checked Resident #3 for incontinence today.
During an interview on 08/04/23 at 11:10 A.M., the Director of Nursing (DON) said he/she expects residents to be checked for incontinence every two hours or as needed. The staff should not go for multiple hours without checking on the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide the nurse aide's annual individual performance review or evaluation for one certified nursing assistant (CNA) out of two sampled CN...
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Based on interview and record review, the facility failed to provide the nurse aide's annual individual performance review or evaluation for one certified nursing assistant (CNA) out of two sampled CNAs. The facility census was 40.
The facility did not provide a policy for nurse aide annual individual performance review or evaluations.
Review of the facility's employee records for July 2022 through August 2023, showed:
- CNA D had a hire date of 01/18/10;
- No documentation that CNA D received an annual individual performance review or evaluation.
During an interview on 08/03/23 at 3:30 P.M., CNA D said he/she had worked at the facility for 14 years and had not received any annual performance reviews.
During an interview on 08/04/23 at 8:45 A.M., the Administrator said they did not perform performance reviews on nurse aides annually.
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 staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at...
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Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two medication carts and one medication storage room. This had the potential to affect all residents. The facility census was 40.
Review of the facility's policy titled, Narcotic Count, undated, showed:
- The purpose is to complete a physical inventory of narcotics at each shift change to identify discrepancies;
- The narcotic supply is to be kept under two locks at all times;
- One Registered Nurse (RN), Licensed Practical Nurse (LPN) or Certified Medication Technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify the accuracy of the narcotics supply for each individual resident at each shift change;
- Narcotic records are reconciled by physical count of the remaining narcotic supply at each shift change by incoming and outgoing licensed nurse. Emergency kits containing narcotics will be checked at the same time to be sure the seal is not broken or will be reconciled if it it is broken;
- After the supply is counted and justified, the nurse/CMT records the date and his/her signatures, verifying the count is correct.
1. Review of the 100/200 hall nurse narcotic count log for the controlled substances showed:
- For 08/01/23- 08/03/23, the staff missed seven out of nine opportunities;
- For 07/0/123 - 07/31/23, the staff missed 57 out of 89 opportunities.
Review of the 300/400 hall nurse narcotic count log for the controlled substances showed:
- For 08/01/23- 08/03/23, the staff missed seven out of nine opportunities;
- For 07/01/23 - 07/31/23, the staff missed 53 out of 89 opportunities.
Review of the emergency kit nurse narcotic count log for the controlled substances showed:
- For 08/01/23- 08/03/23, the staff missed six out of nine opportunities;
- For 07/01/23 - 07/31/23, the staff missed 71 out of 89 opportunities.
During an interview on 08/04/23 at 2:38 P.M., the Director of Nursing (DON) said the narcotics should be counted and logged by two staff with every shift change. It should be done by the oncoming and off going nurse or CMT.
During an interview on 08/04/23 at 2:43 P.M., the Administrator said she would expect the narcotic count to be done by the on coming and off going nurse, and was not aware there were any issues with it not being completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) of a psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) for thr...
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Based on interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) of a psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) for three residents (Resident #3, #23 and #30) out of five sampled residents. The facility's census was 40.
The facility did not provide a GDR policy.
1. Review of Resident #3's medical record showed:
- admission date of 08/01/03;
- Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life), anxiety disorder (persistent worry and fear about everyday situations), bipolar disorder (a mental disorder that causes unusual shifts in mood), and Alzheimer's disease (progressive mental deterioration), and intellectual disabilities;
- An order, dated, 02/26/21, for Trileptal (a mood stabilizer) 600 milligram (mg) one tablet twice a day, for bipolar disorder;
- An order, dated, 06/09/22, for mirtazapine (an antidepressant) 7.5 mg one tablet daily for depression;
- No documentation of an attempted GDR for Trileptal since 06/14/22;
- No documentation of an attempted GDR for Mirtazapine since 06/09/22.
2. Review of Resident #23's medical record showed:
- admission date of 05/30/18;
- Diagnoses of other specified depressive episodes, schizoaffective disorder, unspecified (a condition characterized by abnormal thought processes and deregulated emotions);
- An order, dated, 05/04/20, for Lamictal (a mood stabilizer) 100 mg one tablet twice a day, for schizoaffective disorder, unspecified;
- An order, dated, 03/29/18, for Seroquel (an antipsychotic) 300 mg two tablets daily at bedtime;
- An order, dated, 04/10/19, for Lexapro (an antidepressant) 20 mg one tablet daily for other specified depressive episodes;
- No documentation of an attempted GDR for Lamictal since 08/05/22;
- No documentation of an attempted GDR for Seroquel since 08/05/22;
- No documentation of an attempted GDR for Lexapro since 08/05/22.
3. Review of Resident #30's medical record showed:
- An admission date of 03/08/22;
- Diagnoses of depression, dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), and insomnia (difficulty sleeping);
- An order, dated, 03/31/22, amitriptyline (an antidepressant) 25 mg one tablet daily for depression;
- An order, dated 03/08/22, for temazepam (a hypnotic that produces sedation) 15 mg one capsule at bedtime, for insomnia;
- A pharmacist GDR request for amitriptyline 25 mg and temazepam 15 mg, dated 08/22/22, and signed by the physician on 10/25/22, with the GDR refused as contraindicated. No documentation from the physician for the reason the GDRs were contraindicated;
- On 01/20/23, a note to see recommendations regarding GDR review;
- On 02/23/23, a note to see the report;
- On 03/27/23, a note to see the recommendation regarding GDR review;
- On 04/18/23, a note to see recommendation regarding GDR review of psychotropic medications;
- No documentation of the recommendations or the results of the recommendations for the notes of 01/20/23, 02/23/23, 03/27/23, and 04/18/23.
During an interview on 08/03/23 at 11:00 A.M., the Director of Nursing (DON) said pharmacy recommendations were faxed to the physician. They took a long time to come back sometimes. Better documentation should be kept to show this was being done.
During an interview on 08/04/23 at 2:00 P.M., the Administrator said the facility did not have a policy about GDRs but followed the guidance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordanc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility also failed to ensure one resident (Resident #13) outside of the sample of 12 residents had a physician's order to keep an inhaler (hand-held portable device that delivers medication to the lungs) at the bedside and to store medications in a safe and effective manner when staff left the medications cart unlocked and unattended, leaving the narcotics behind only one lock. This had the potential to affect all residents The facility census was 40.
Review of the facility's policy titled, Bedside Medication Storage,dated 3/2015, showed:
- If a resident expresses a desire to self-administer medication, the interdisciplinary team (team members from different disciplines who actively coordinate to work toward shared treatment goals) must assess the resident's cognitive, physical and visual ability to carry out this responsibility. The mental status and any psychiatric diagnoses must be taken into account. The Evaluation Assessment to Self-Administer Medications will be used for this purpose;
- When the resident self-administers medication, the resident will be re-assessed on an ongoing basis for continued safety of this practice. The evaluation assessment will be completed annually or with a significant change by nursing and reviewed by the interdisciplinary team to determine if the resident is still capable of self-administering medications;
- For self-administration of prescription medications to be kept at the bedside: the resident will be assessed as outlined in step 1 and 2; A physician's order will be obtained for each medication to be kept at the bedside; The resident will receive a set amount of medication for a set number of days; The medications will be listed on the Medication Administration Record (MAR) and show they are self-administered/kept at the bedside; The resident's care plan will instruct staff where medication is to be stored and who will document the administration of the medication; The nurse will interview the resident periodically and assess the number of medications remaining. If at any time there is a question as to the continued safety of this practice, the nurse will initiate the re-assessment process; The nurse will document the findings during the resident interview. They will also document the required monthly education given to the resident regarding any medication kept at the bedside.
Review of the facility's policy titled, Storage of Medications, undated, showed:
- All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more mobile medication carts;
- All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room or otherwise made immobile;
- All controlled substances must be stored under double lock and key;
- An unattended medication cart must remain locked at all times;
- No outdated drugs or biologicals may be retained for use. They must be returned to the issuing pharmacy or destroyed in accordance with established guidelines.
1. Review of Resident #13's Physician Order Sheet (POS), August 2023, showed:
- An order for albuterol sulfate hydrofluoroalkane (HFA) (a type of propellant spray) aerosol inhaler; (an airway dilator inhaler used for chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) 90 microgram (mcg) one puff every four to six hours as needed, dated 02/07/20;
- No documentation of an order for the resident to keep the albuterol sulfate HFA inhaler at the bedside and the resident could self-administer the medication;
- No documentation of the evaluation assessment for the resident to self-administer medications;
- No documentation of the monthly education provided to the resident regarding medication kept at the bedside;
- The resident's care plan, dated 6/28/23, did not address any medications to be kept at the bedside or self-administered.
Observation on 08/02/23 at 1:07 P.M., showed Resident #13 had his/her albuterol sulfate HFA 90 mcg aerosol inhaler his/her hand in a common area of the facility.
Observation on 08/03/23 at 11:15 A.M., showed Resident #13's albuterol sulfate HFA 90 mcg aerosol inhaler in a clear plastic bag sat on a table in the dining area of the facility.
During an interview on 08/03/23 at 1:07 P.M., Resident #13 said he/she brought the inhaler to a meeting with him/her in case it was needed.
During an interview on 08/03/23 at 11:15 A.M., Resident #13 said he/she kept the inhaler in his/her bedside table at night. Otherwise he/she kept it on his/her person in case it was needed. He/She knew how to use it properly so staff had never trained him/her on how to use it.
During an interview on 08/04/23 at 4:50 P.M., the Administrator said she would expect a resident to have an order from a physician for a medication to be kept at the beside, for it to be addressed in the resident's care plan, and for the resident to be assessed and educated on how to self-administer the medication quarterly.
2. Observations on 08/01/23 of the medication pass showed:
- At 12:11 P.M., Certified Medication Technician (CMT) B left the medication cart unlocked and unattended outside the dining room facing the hall on the Unit, administered medications to a resident in his/her room and returned to the medication cart at 12:12 P.M.;
- At 12:12 P.M. CMT B left the medication cart unlocked and unattended outside the dining room facing the hall on the Unit, as he/she administered medication to a resident in the dining room, returned to the medication cart at 12:12 P.M., and pushed it off the unit;
- At 12:14 P.M., the medication cart sat outside the main dining room facing the 300 hall and CMT B left the medication cart unlocked and unattended as he/she administered medications to a resident on the other side of the dining room and returned to the medication cart at 12:15 P.M.;
- At 12:15 P.M., CMT B left the medication cart unlocked and unattended as he/she administered medications to a resident in the dining room and returned to the medication cart at 12:16 P.M.;
- At 12:20 P.M., CMT B left the medication cart unlocked and unattended as he/she administered medications to a resident in the dining room and returned to the medication cart at 12:21 P.M.;
- At 12:22 P.M., CMT B left the medication cart outside the main dining room facing the 300 hall unlocked and unattended as he/she administered medications to a resident in room [ROOM NUMBER] and returned to the medication cart at 12:23 P.M.;
- At 12:25 P.M., CMT B left the medication cart outside the main dining room facing the 300 hall unlocked and unattended as he/she administered medications to a resident in room [ROOM NUMBER] and returned to the medication cart at 12:27 P.M.;
- Narcotics were locked under one lock only for a total of eight minutes while medications were passed and the medication cart was left unlocked.
Observations on 08/03/23 of the medication pass showed:
- At 8:20 A.M., RN A left the unlocked and unattended medication cart facing toward the hall at the door of room [ROOM NUMBER], entered the room to administer the resident's medication, and returned to the cart at 8:21 A.M.;
- At 8:23 A.M., RN A left the unlocked and unattended medication cart facing toward the hall at the door of room [ROOM NUMBER], entered the room to administer the resident's medication, and returned to the cart at 8:24 A.M.;
- At 8:25 A.M., RN A left the unlocked and unattended medication cart facing toward the hall at the door of room [ROOM NUMBER], entered the room to administer the resident's medication, and returned to the cart at 8:27 A.M.;
- Narcotics were locked under one lock only for a total of four minutes while medications were passed and the medication cart was left unlocked.
During an interview on 08/01/23 at 1:30 P.M., CMT B said the medication cart should always be locked when left unattended.
During an interview 08/04/23 at 2:38 P.M., the Director of Nursing (DON) said the medication cart should be locked before walking away from it and the narcotics should be kept behind two locks.
During an interview 08/04/23 at 2:43 P.M., the Administrator said she would expect the medication cart to be facing the wall or a resident room and be locked before walking away from it.
3. Observation of the medication room on 08/04/23 at 9:08 A.M., of the stock cabinets showed:
- Two boxes of six mineral oil enemas (treats occasional constipation) with an expired date 02/2022;
- One box of major gas relief medication (treatment for relief of pressure and bloating) with an expired date 07/2023;
- One box of Geri saline nose spray (used for allergy symptoms of clogged or runny nose) with an expired date 07/2023.
Observation of the medication room on 08/04/23 at 9:15 A.M., of the medication refrigerator showed
- One vial of influenza vaccine (a vaccine that protects against the flu infection), open and undated;
- One vial of purified protein derivative (PPD) (used to diagnose silent tuberculosis infection), open and undated.
During an interview 08/04/23 at 2:45 P.M., the DON said there was no specific person that checks the medications. She was trying to keep them checked and went through them monthly.
During an interview 08/04/23 at 2:50 P.M., the Administrator said she would expect the expired medications to be discarded and medications dated when opened.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain quarterly Quality Assurance Assessment (QAA) Committee (those responsible for identifying and responding to quality deficiencies t...
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Based on interview and record review, the facility failed to maintain quarterly Quality Assurance Assessment (QAA) Committee (those responsible for identifying and responding to quality deficiencies that are identified in the facility) meetings with the required members. The facility's census was 40.
Review of the facility's 2023 Quality Assurance and Performance Improvement (QAPI) (a program to improve processes for the delivery of health care and quality of life for the resident) Plan showed:
- The purpose will be to take a proactive approach to continually improve the way staff care for and engage with the residents, caregivers, and other partners. To do this, all employees will participate in the ongoing QAPI efforts which support the facility's vision and mission;
- Key monitors are measured and trended on a quarterly basis;
- At minimum, the leadership will report annually on the status of the current QAPI plan as well as the proposed plan and goals for the coming year;
- In addition, the QAPI Steering Committee will implement any Performance Improvement Projects (PIP) topics indicated by data analysis;
- At a minimum, the QAPI Steering Committee will analyze performance to identify and follow-up on areas;
- At a minimum, the executive leadership and the facility management teams, along with the assistance of the QAPI Steering Committee, will conduct a facility-wide systems evaluation utilizing the Self-Assessment.
Review of the facility's QAPI plan showed:
- QAPI policies and procedures reviewed in 2023;
- No tracking, measures taken for issues/concerns, or documentation of any 2023 meetings.
Review of the facility's QAA book showed:
- Flow charts, information, and other documentation tools to assist with starting the program;
- The last documented meeting on 12/27/22;
- No documented meetings in 2023;
- QAA Committee to consist of the Administrator, the Medical Director, the Director of Nursing (DON), the Social Services Director (SSD) and the Minimum Data Set (MDS) (a federally mandated process for clinical assessment of all residents in certified nursing homes) Director;
- No documentation the facility maintained the minimum required quarterly QAA meetings with the required members.
During an interview on 08/04/23 at 2:51 P.M., the DON said she had not attended any QAA meetings.
During an interview on 08/04/23 at 2:59 P.M., the SSD said he/she had never attended any QAA meetings.
During an interview on 08/04/23 at 3:06 P.M., the Administrator said the last QAA meeting was in June 2023, and thought she had brought a form in. The meeting consisted of the Medical Director, the previous book keeper, and herself. There was not a March 2023 meeting. They should have met at least quarterly and the meetings consisted of whoever of the committee was available at that time. Also, they had not performed any PIPs, so there was no tracking for any problems corrected.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide and document residents received or declined appropriate imm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide and document residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or a resident's representative regarding the benefits, side effects, or warnings of those immunizations for four residents (Residents #7, #10, #36 and #40) out of five sampled residents. The facility census was 40.
Review of the facility's policy titled, Immunizations, undated, showed:
- Resident's physician will be consulted and determine the level of risk and need for vaccinations;
- A physician order is required to administer any medication/vaccination;
- Influenza (flu) is recommended annually for all residents;
- Pneumococcal (an infection caused by a type of bacteria that can cause pneumonia) vaccination in persons ages 65 years and older, unless contraindicated
- Adults 65 years or older who have not already received a Pneumococcal conjugate vaccine should receive either a single dose of Pneumococcal conjugate vaccine 15 (PCV15) (pneumonia vaccine that protects against 15 Pneumococcal bacteria) followed by a dose of Pneumococcal polysaccharide vaccine 23 (PPSV23) (pneumonia vaccine that protects against 23 Pneumococcal bacteria) one year later, or a single dose of Pneumococcal conjugate vaccine 20 (PCV20 (pneumonia vaccine that protects against 20 Pneumococcal bacteria);
- Adults 65 years or older who have already received PPSV23 should receive a single dose of PCV15 or PCV20. The dose should be administered at least one year after the most recent PPSV23 vaccination;
- Requirements to administer the vaccination includes: physician order, consent to receive signed by the resident and/or legal representative, information sheet included with the consent, and monitor the resident for fever up to 72 hours.
1. Review of Resident #7's medical record showed:
- admitted on [DATE];
- Over [AGE] years of age;
- No documentation of the refusal or education of the Pneumococcal vaccination information provided to the resident and/or the resident's legal representative;
- No documentation the resident received the Pneumococcal vaccination.
Review of Resident #10's medical record showed:
- admitted on [DATE];
- Over [AGE] years of age;
- No documentation of the refusal or education of the flu or Pneumococcal vaccinations information provided to the resident and/or the resident's legal representative;
- No documentation the resident received an annual flu vaccination;
- No documentation the resident received the Pneumococcal vaccination.
Review of Resident #36's medical record showed:
- admitted on [DATE];
- Over [AGE] years of age;
- No documentation of the refusal or education of the flu or Pneumococcal vaccinations information provided to the resident and/or the resident's legal representative;
- No documentation the resident received an annual flu vaccination;
- No documentation the resident received the Pneumococcal vaccination.
Review of Resident #40's medical record showed:
- admitted on [DATE];
- Over [AGE] years of age;
- No documentation of the refusal or education of the flu or Pneumococcal vaccinations information provided to the resident and/or the resident's legal representative;
- No documentation the resident received an annual flu vaccination;
- No documentation the resident received the Pneumococcal vaccination.
During an interview on 08/04/23 at 1:23 P.M., the Director of Nursing (DON) said vaccinations should be documented and recorded. The resident and/or family member should be asked upon admission and then annually. The administration of the vaccine or refusal should be documented in the resident's medical record. The risk and benefit page should be given at that time, signed, and put into the resident's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. This de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 40.
Observation on 08/04/23 at 11:05 A.M., of the building showed:
- Water dripped from a light fixture into a 6 inch (in.) puddle on the floor in front of the admissions office;
- A 6 in. brown stain on the ceiling near the speaker by the business office;
- A 1 in. by 6 in. brown stain to the left and right of the light fixture located in the ceiling outside the business office;
- A 4 in. dark brown ring on the ceiling near room [ROOM NUMBER];
- An approximately 8 to 10 in. brown stained area on the dining room ceiling;
- Multiple brown rings on the ceiling in the dining room near the window;
- Damage to five ceiling tiles in the hallway outside of rooms [ROOM NUMBERS];
- Five brown streaks down the wall approximately 8 feet long between rooms [ROOM NUMBERS];
- Damage to the edges of the ceiling tile in room [ROOM NUMBER];
- A 6 in. section of paint peeling from the wall in the hallway above employee lounge door on the 500 hallway;
- A 2 foot section of vinyl cove base missing behind the exit door outside the laundry room on 500 hall;
- Two chairs located in the resident sitting area between the business office and the bathrooms had cracked arms;
- Both arms of Resident #5's wheelchair were cracked;
- An 8 in. by 2 in. section of damage to the sheetrock in the corner behind the recliner in resident room [ROOM NUMBER];
- Resident room [ROOM NUMBER] had damage to the top edge of the end table near the door, missing trim on the end table nearest the window and a dark ring stain around the toilet in the bath.
During an interview on 08/04/23 at 2:20 P.M., Resident #20 said the floor of the bathroom in room [ROOM NUMBER] looked dirty and had needed repairs since he/she moved in.
During an interview on 08/04/23 at 1:50 P.M., the administrator said if something needed to be fixed in the building they will tell the Maintenance Director or write it on the white board. The administrator said earlier this week, they provided a system where staff can note items they see in need of repair on a paper and keep at the nurse's station. The Maintenance Director will check for the papers when he/she comes on duty.
The facility did not provide a policy related to environment or building maintenance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for six residents (Residents #4, #7, #9, #10, #36 and #40) out of 12 sampled residents. The facility census was 40.
Review of the facility's policy, titled, Care Plans, Comprehensive Person-Centered, undated, showed:
- An individualized comprehensive care plan will include measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being;
- The comprehensive care plan will be based on a thorough assessment;
- Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition;
- A well developed care plan will: Be developed within seven days of the completion of the Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff; Prevent avoidable decline in function; Manage risk factors to the extent possible or indicating the limits of such interventions; Preserve and build on the residents strengths; Apply current standards of practice; Respect the resident's rights to decline treatment; Offer alternative treatments; Involve direct care staff with the care planning process.
1. Review of Resident #4's medical record showed:
- Diagnoses of multiple sclerosis (a disease that results in nerve damage disrupting the communication between the brain and body), contracture of the left ankle, contracture of the right ankle,
- An order on the August 2023 Physician's Order Sheet (POS), dated 04/13/21, for Dynasplint (a stretching device that helps increase joint range of motion) braces to be worn eight hours per day while supine (on the back with the face and abdomen facing up) in bed;
- No documentation related to the resident's use or non-compliance of the braces;
- No order on the August 2023 POS for a trapeze (an assistive device that hangs above the resident's head to assist facilitate movement and positioning);
- A Smoking assessment, dated 06/16/22, identified the resident a safe smoker;
- The annual MDS, dated [DATE], showed the resident smoked.
Observations of the resident showed:
- On 08/01/23 at 10:14 A.M., a sign on the resident's closet door showed the resident was to wear foot braces while in bed. No trapeze attached to the resident's bed;
- On 08/01/23 at 10:14 A.M., the resident lay in bed with no braces on his/her feet. No trapeze attached to the resident's bed;
- On 08/02/23 at 10:26 A.M., the resident lay in bed with no braces on his/her. No trapeze attached to the resident's bed;
- On 08/03/23 at 8:51 A.M., the resident lay in bed with no braces on his/her feet. No trapeze attached to the resident's bed.
Review of the resident's care plan, revised on 06/21/23, showed:
- The care plan did not address the Dynasplint braces with individualized interventions;
- Trapeze used to assist the resident with bed mobility;
- The care plan not updated to address the trapeze was no longer used;
- The care plan did not address the resident smoked with individualized smoking interventions.
During an interview on 08/02/23 at 12:43 P.M., Resident #4 said the braces were not on and they hadn't been for a month or more. He/She thought the braces were worn to help keep his/her ankles straight, and didn't know why they weren't on, but they just hadn't been put on. He/She smokes, but but hadn't in a few days. When he/she does smoke, staff is present and sometimes puts an apron on him/her. Resident #4 did not know why the trapeze was removed.
During an interview on 08/02/23 at 3:10 P.M., the Administrator said Resident #4 was the only resident that should use a smoking apron, but one was not always used. It should be used because the resident can't really even hold a pencil anymore and the care plan should address that.
During an interview on 08/03/23 at 8:51 A.M., RN A said he/she thought the resident was supposed to have the braces on when he/she was out of bed and up in the chair. One pair of braces was found but it was not the ones the resident was supposed to wear. The care plan should reflect the resident's condition/needs.
During an interview on 08/03/23 at 1:20 P.M., the Administrator said she was sure the resident was non-compliant with the foot braces, and staff was unable to find them now. It should be documented if the resident was non-compliant. She would expect the care plan to be revised to reflect the resident's condition and care needed. The Administrator said the best she remembered, the resident hit his/her eye on the trapeze and wanted it taken down. She would expect the care plan to be revised to reflect the resident's condition and care needed.
2. Review of Resident #7's medical record showed:
- An admission date of 06/05/23;
- Diagnoses of history of falling, muscle weakness, difficulty in walking, Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), and spinal stenosis (a narrowing of the spinal canal in the lower part of the back);
- Required assistance of one to two staff for toileting;
- admission MDS assessment, dated 06/12/23, showed the resident did not use an alarm;
- No documentation of a physical restraint assessment.
Review of the resident's care plan, reviewed on 07/30/23, showed:
- The resident had falls;
- An intervention of a wheelchair alarm while up in the wheelchair, dated 06/19/23;
- The care plan did not address the wheelchair alarm as a risk with interventions.
Observations of the resident showed:
- On 08/01/23 at 10:59 A.M., the resident sat in a wheelchair with a chair alarm on in the common area;
- On 08/02/23 at 8:46 A.M., the resident sat in a wheelchair with a chair alarm on in the common area;
- On 08/03/23 at 8:10 A.M., the resident sat in a wheelchair with a chair alarm on in the common area;
- On 08/04/23 at 8:15 A.M., the resident sat in a wheelchair with a chair alarm on in the common area
3. Review of Resident #9's medical record showed an admission date of 07/19/23.
Review of the resident's Lift Assessment, dated 07/19/23, showed the resident required a minimum of three staff or a mechanical lift (a device used to assist with transfers) for lift/transfer.
Review of the resident's comprehensive care plan, dated 07/26/23, showed the plan did not address transfers and individualized transfer interventions.
During an interview on 08/03/23 at 2:27 P.M., the Director of Nursing (DON) said the resident required a two person assist with a gait belt for transfers and the required assistance should be addressed on the care plan.
During an interview on 08/03/23 at 2:29 P.M., Registered Nurse (RN) A said his/her understanding was that the resident required a Hoyer (an assistive device used to lift and transfer residents from one surface to another) lift for transfers and it should be on the care plan.
During an interview on 08/03/23 at 2:35 P.M., Nursing Assistant (NA) G said he/she just manually picked the resident up to transfer him/her. That was how he/she was shown to do it. He/She wasn't sure who showed him/her or about the care plan.
4. Review of Resident #10's medical record showed:
- Diagnosis of benign prostatic hyperplasia (enlarged prostate gland that can cause urination difficulty);
- An order for a supra pubic catheter (a hollow tube inserted into the bladder through a small hole in the abdomen used to drain the the urine), dated 08/22/22;
- An order to provide a leg collection bag and secure it with a catheter strap when the resident was out of the bed, dated 06/01/22.
Observations of the resident showed:
- On 08/01/23 at 9:36 A.M., the resident sat in a wheelchair with the catheter collection bag hung under the wheelchair in the dining room;
- 08/01/23 at 1:34 P.M., the resident sat in a wheelchair with the catheter collection bag hung under the wheelchair in the dining room;
- 08/02/23 at 8:42 A.M., the resident sat in a wheelchair with the catheter collection bag hung under the wheelchair in the dining room;
Observation 08/04/23 at 11:42 A.M., the resident sat in a wheelchair with the catheter collection bag hung under the wheelchair in the dining room.
Review of the resident's care plan, revised on 07/07/2023, showed:
- The resident had urinary incontinence, dated 04/06/22;
- Provide incontinent care after any incontinent episode;
- The goal of the resident will be to remain clean, dry and odor free with no skin breakdown;
- The care plan not updated to address the urinary catheter or any individualized interventions for catheter care.
5. Review of Resident #36's medical records showed diagnosis of dementia (a disease that impairs at least two brain functions, such as memory loss and judgment).
Observations of the resident showed:
- On 8/1/23 at 1:00 P.M., the resident walked independently with no assistive devices;
- On 8/3/23 at 10:30 A.M., the resident walked independently with no assistive devices;
- On 8/4/23 at 3:00 P.M., the resident walked independently with no assistive devices.
Review of the resident's care plan, dated 07/04/23, showed:
- The resident had an unsteady gate and wheelchair bound;
- The care plan did not address the resident walked independently with no assistive devices.
During an interview on 8/4/23 at 4:50 P.M., the Administrator said she would expect care plans to reflect the residents' needs including how they ambulate, transfer, assistive devices and needs, such as catheters. She said the MDS Coordinator was supposed to update the care plan, but he/she could also make changes to the care plans if she was made aware of them. The updates should be made as soon as a change had been identified.
6. Review of Resident #40's medical record showed:
- The admission MDS, dated [DATE], indicated the resident smoked;
- No documentation of a smoking assessment.
Observations of the resident showed:
- On 08/03/23 at 11:25 A.M., the resident smoked with two visitors in the designated smoking area;
- On 08/03/23 at 11:28 A.M., the Administrator opened the door for the resident and her visitors to return inside the building.
Review of the resident's care plan, revised on 05/11/23, showed did not address the resident smoked with individualized smoking interventions.
During an interview on 8/03/23 at 11:25 A.M., the Administrator said she would expect care plans to reflect the resident's needs including smoking. Resident #40 was allowed to smoke outside without staff supervision as long as his/her visitor was present.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This ...
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Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 40.
Review of the facility's policy titled, Nutrition and Dining Services Manual policy, dated May 2015, showed:
- It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks;
- Develop detailed cleaning schedules to ensure sanitation is at acceptable standards.
Review of the facility's Food Storage policy, undated, showed:
- All foods will be considered as leftovers unless in the original container with an expiration date;
- Leftovers will be discarded after third storage day;
- All food will be stored in appropriate containers.
1. Observation on 08/01/23 at 9:45 A.M., of the dry food storage room, showed:
- One 35 pound (lb.) cooking oil container sat on the floor;
- One 7 lb. dented can with apple pie filling on the canned food rack;
- Three undated peanut butter sandwiches in clear sandwich bags;
- Scattered debris below the food storage shelves.
2. Observation on 08/01/23 at 9:55 A.M., of the walk-in refrigerator, showed:
- One potato, four condiment packs, a sticky film and debris on the floor below the food shelves;
- Dust and grime build-up between the ventilation louvers.
3. Observation on 08/01/23 at 10:01 A.M., of the walk-in freezer showed:
- Six 1 inch (in.) ice formations hung 4 in. from the area below the ventilation louvers;
- Two food boxes below the ventilation louvers covered with 1 in. ice build-up;
- The floor with 1 in. thick ice formation below the food shelves.
During an interview on 08/01/23 at 10:06 A.M., the Dietary Manager said the walk-in freezer had a problem with ice build-up. It should be working properly but wasn't. The Maintenance Director had been notified about the concern. There should not be ice coated on the food boxes or on the floor of the freezer.
4. Observation on 08/01/23 at 10:10 A.M., of the kitchen showed:
- The commercial range with brown grime build-up around the control knobs;
- Debris, oily film build-up, a fried chicken leg and food debris on the floor beneath the range;
- The commercial style can opener with a worn cutting edge, black grime build-up, and base edges with a brown substance;
- The commercial dishwasher with white grime build up on the exterior surfaces.
5. Observation on 08/02/23 at 10:15 A.M., of the kitchen showed:
- The commercial range with brown grime build-up around the control knobs;
- Debris, oily film build-up, a fried chicken leg and food debris on the floor beneath the range;
- The commercial dishwasher with white grime build up on the exterior surfaces and a wet towel in the floor below it;
- The dishwasher vent hood with a brown substance inside;
- Black grime build-up on the drain pipes below the dishwashing counter.
6. Observation on 08/03/23 at 9:14 A.M., of the kitchen showed:
- An 8 foot (ft.) worn cabinet top with a non-intact Formica surface;
- A cabinet drawer with six ice cream scoops, six large spoons, one plastic organizer with debris and one roach crawled around inside;
- Three 16 in. x 24 in. x 1 in. and three 16 in. x 12 in. x 1 in. deep baking pans with a sticky film, black grime build-up in the inside corners, on the cooking surface and outer surfaces;
- Nine ceiling diffusers (one of the few visible parts of an air conditioning system) with brown grime build-up on the front exterior surfaces and between the ventilation louvers.
7. Observation on 08/04/23 at 9:45 A.M., of the dry food storage room showed:
- One can of tomato soup lay on the floor below the food shelving;
- One 4 ft. section of vinyl baseboard missing behind the food shelving;
- One opened plastic bag with 5 lb. devil's food cake mix, dated 04/16/23;
- One 15 ounce (oz.) cardboard can with graham cracker crumbs and a use by date of 01/29/23;
- One undated, 5 gallon plastic container with cornmeal without a label;
- One 8 in. x 8 in. ceiling diffuser with black grime build up between the louvers;
- Two 12 in. x 12 in. vinyl floor tiles with 2 in. broken corner sections.
During an interview on 08/02/23 at 10:18 A.M., the Dietary Manager said fried chicken was made two weeks ago. The fried chicken leg under the range must had been made then and sweeping under the appliances was not always done correctly. The dishwasher was serviced by an outside company but it leaked. There was corrosion inside the vent. The leak under the dishwasher had caused mold under the dishwasher and the counter area.
During an interview on 08/02/23 at 10:22 A.M., the Registered Dietician said the dishwasher leaked and possibly caused a recent gnat problem in the past five months. A service company would be contacted about the leaky dishwasher because it should be fixed. The dishwasher, appliances and floor surfaces should be cleaned. The walk-in freezer had an automatic defrost mode and caused food boxes to become coated with ice when they were stored below the ventilation unit. Food boxes should not be stored there. The ceiling vents in the kitchen should be clean and maintenance would be asked to get them cleaned.
During an interview on 08/03/23 at 9:14 A.M., the Dietary Manager said the kitchen was sprayed for bugs every two or three months by an outside pest control company and there hadn't been bugs seen in a while. The roach would be removed from the drawer and cleaned out. The Formica countertop surface should be clean and intact. The can opener should be cleaned after each use but staff had been unable to remove the brown substance, but it should look clean. The walk-in freezer and food boxes should not have ice build-up and some food boxes under the ventilation unit had been removed. The floors in the walk-in freezer and refrigerator should be cleaned and mopped every night. The baking sheets should be clean with no sticky film or carbon build-up.
During an interview on 08/04/23 at 9:50 A. M., Dietary Aide L said expectations were to follow the facility's kitchen policy, keep the kitchen clean and leftovers should be thrown out after three days.
Expired foods should not be kept in storage.
During an interview on 08/04/23 at 5:27 P.M., the Administrator said the freezer and refrigerators should be clean. The ceiling vents should be clean and not have dust or grime build up. All appliances, counter tops and vents should be clean and work properly. There should not be bugs in the kitchen but a roach was found in the kitchen drawer yesterday. Hall trays should not be served without proper sanitization.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to ...
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Based on observation and interview, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 40.
The facility failed to provide a policy regarding dumpster maintenance.
1. Observation of the dumpster area on 08/01/23 at 4:00 P.M., and 5:02 P.M., showed:
- One 8 yard (yd.) dumpster partially filled with one plastic lid completely opened.
2. Observation of the dumpster area on 08/02/23 at 11:44 A.M., and 12:42 P.M., showed:
- One 8 yd. dumpster partially filled with one plastic lid completely opened.
3. Observation of the dumpster area on 08/03/23 at 4:05 P.M., and 5:02 P.M., showed:
- One 8 yd. blue dumpster partially filled with one plastic lid completely opened;
- Three clear disposable gloves lay on the ground near the dumpster with other scattered debris.
4. Observation of the dumpster area on 08/04/23 at 9:43 A.M., and 10:32 A.M., showed:
- One 8 yd. blue dumpster partially filled with one plastic lid completely opened;
- A 12 inch (in.) square drain cover plugged with grass clippings and debris beside the dumpster;
- Four inches of rain water surrounded the dumpster area;
- Three clear disposable gloves lay on the ground near the dumpster with other scattered debris.
During an interview on 08/04/23 at 10:47 A.M., the Maintenance Director said the trash dumpster should be closed when it was unattended.
During an interview on 08/04/23 at 11:00 A.M., the Dietary Manager said facility staff were expected to close the lid when finished and ensure the area around the dumpster was clean.
During an interview on 08/04/23 at 5:27 P.M., the Administrator said the dumpster area should be kept in order and the lid should be closed when it was not being filled. The area around the dumpster should be clean and the storm drain should be clear near the dumpster.
May 2023
3 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident after a fall and failed to investigate, document,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident after a fall and failed to investigate, document, assess and treat in a timely manner one resident (Resident #1) of three sampled residents. On [DATE] at 4:00 A.M., the resident fell to the floor and no notifications, interventions or assessment took place until 1:30 P.M. that afternoon, seven hours later, when Resident #1 was sent to the hospital and diagnosed with a displaced hip fracture. The facility census was 41.
The facility did not provide a policy regarding falls or post fall protocol.
1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated [DATE] showed:
- admission to facility on [DATE];
- Diagnoses of Alzheimer's disease ( a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, the disease involves parts of the brain that control thought, memory, and language), dementia with behavioral disturbances (Behavioral disturbances in dementia are often globally described as agitation including verbal and physical aggression, excessive wandering, and sleep disturbance), anxiety, major depressive disorder (Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living), lack of coordination (lost of balance);
- Cognition impaired;
- Delirium with fluctuating behaviors of inattention and disorganized thinking, comes and goes and changes in severity;
- Behaviors of wondering daily;
- Requires supervision of one staff member for exiting secure unit;
- Occasionally incontinent of bowel and bladder;
- Receives antipsychotic ( medication that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) and antidepressant medications seven days a week on a routine basis;
- Guardian in place.
Review of the Resident #1's Care Plan, showed:
- At risk for falls related to diagnosis of Alzheimer's and overestimates abilities at times;
- Resident resides on the special care unit due to diagnosis of Alzheimer's;
- The resident has difficulty making safe decisions related to a history of dementia;
Review of the resident's [DATE] Physician Order Sheet (POS), showed:
- No order for pain/fever reducing medications;
- No order to send resident to emergency room for evaluation;
- No orders or instructions for post-fall monitoring such as neuro-checks.
Review of the progress notes showed:
- On [DATE] at 4:10 A.M., resident entered other resident rooms, when told not to enter the room resident became combative with the staff and attempted to hit staff. The resident then threw self into floor and started screaming and hollering for help and saying she hit me, staff assisted the resident back to his/her room, will continue to monitor;
- On [DATE] at 2:06 P.M., the resident complained of severe pain to the right pelvic area due to a fall this morning. Contacted the resident Power of Attorney (POA) (a legal document allowing a person to act on your behalf), ambulance responding to facility to transport resident to hospital.
Review of Resident #1 hospital report dated [DATE] through [DATE] showed:
- Resident #1 admitted with displaced right hip fracture;
- Resident expired on 0 [DATE] with cause of death listed as Alzheimer's disease and right hip fracture.
The facility did not provide any investigation of the fall or post fall assessment of the resident.
During a interview on [DATE] at 10:45 A.M., Registered Nurse (RN) A said on [DATE] during shift report, the previous nurse, RN B, did not give any report on Resident #1's behaviors or changes in condition. RN A said his/her shift began as usual, going to the special care unit at approximately 6:30 A.M. Upon entering the unit a staff member informed him/her Resident #1 had thrown him/herself in the floor on the prior shift. RN A said he/she went to the resident's room to assess and found the resident's right leg bent at the knee with rotation (indicating a fracture). The resident cried out in pain when touching the knee/pelvic/hip area. RN A said he/she was surprised the night shift nurse did not notice the rotation in the right leg due to it was very obvious. RN A said he/she did not notify the physician or family, and did not administer any pain medications to the resident. RN A said he/she waited for the Administrator to come to work and assess the resident. At approximately 1:30 P.M. (seven hours later) the Administrator came in and they both decided to notify the family and call an ambulance to transfer the resident to the emergency room. RN A said time got away from him/her with other duties and the Administrator had left the building, so he/she did not remember to inform her (administrator) he/she needed her to look at Resident #1 until later that afternoon. When asked if the resident was in pain that entire time, RN A did not respond. When asked why no pain medications were administered upon the initial observation of the injury, RN A did not respond. When asked why the doctor and family were not contacted upon discovery, RN A did not respond. When asked what the facility's policy on post-fall monitoring was, RN A did not respond. When asked why he/she felt the resident needed the Administrator's assessment prior to any interventions, RN A did not respond.
During an interview on [DATE] at 1:25 P.M., Certified Nurse Aide (CNA) C said he/she was working the special needs unit during the night shift on [DATE]. At approximately 4:00 A.M., CNA C went to the employee rest room on the unit. When CNA C came out, Resident #1 was standing at the door attempting to get past him/her to get into the bathroom. CNA C said he/she tried to assist the resident to turn around when the resident suddenly went to the floor, landed on his/her knees, screamed and slapped the floor and rolled around. RN B heard the commotion and came onto the unit along with CNA D. RN B checked the resident's vital signs while the resident was holding his/her right knee. RN B directed CNA C and CNA D to get the resident off the floor and assist Resident #1 to his/her room. The resident limped on the right leg from where he/she fell to his/her room at the opposite end of the hall. The resident then remained in his/her room screaming for an unknown person and her spouse. No other interventions were done that he/she is aware of. CNA C said Resident #1 had been limping prior to the fall due to a blister on the right foot, but had not appeared to be in the extreme pain he/she was exhibiting after the incident.
During an interview on [DATE] at 2:35 P.M., CNA D said RN B ask him/her to assist on the special needs unit on [DATE] at 4:00 A.M. to help get Resident #1 off the floor. Upon entering the unit CNA D observed Resident #1 on the floor on his/her left side crying out and asking for his/her spouse. When RN B attempted to move the resident's right leg Resident #1 screamed out with pain, the staff attempted to get the resident to sit in a wheelchair but he/she refused, so he/she and CNA C walked Resident #1 to his/her room while the resident limped and cried. CNA D said the resident was obviously in a great deal of pain.
During a telephone interview on [DATE] at 2:45 P.M., RN B said CNA C had called him/her to the unit saying Resident #1 put him/herself on the floor. Upon arrival, RN B saw Resident #1 on the floor yelling he/she pushed me and broke my leg referring to CNA C. The resident was holding his/her right leg. RN B said he/she knew Resident #1 had previously had a blister on his/her right foot, and thought that was why he/she held the right leg. The staff assisted the resident to his/her room. The resident limped and cried during the walk to his/her room. The resident continued to cry as staff assisted him/her to lay on the bed. RN B said he/she looked at the resident legs and did not notice any deformities. RN B said he/she asked the resident if he/she was in pain and the resident would point at his/her lower leg. RN B said he/she did not administer any pain medication at that time because the resident denied being in pain. When asked why he/she thought the resident would respond to being asked about pain by pointing at his/her right leg was not an indication of pain, RN B did not respond. RN B said he/she went back about an hour later and the resident was still crying and yelling out for his/her spouse. At that time, he/she administered an antianxiety medication to calm the resident. RN B said he/she did not go back and check the resident again. RN B said neither the family, nor the physician was notified. When asked why no pain medications were given when the resident indicated her leg hurt during the initial incident, RN B did not answer. When asked why after waiting an hour and finding the resident still crying, no pain medications were given or pain assessment completed, RN B did not answer. When asked what the facility's policy for post fall assessment was, RN B said he/she did not consider the resident dropping to the floor a fall, he/she felt it was a behavior. RN B believed he/she did share the condition of the resident with the oncoming shift as is the policy.
During an interview on [DATE] at 3:15 P.M., the Administrator said on [DATE] at 1:30 P.M., RN A notified her of Resident #1 having thrown him/herself in the floor during the night shift and had visible rotation on the right lower leg. She accompanied RN A and assessed the resident. Resident #1 had rotation noted on the right leg. She then advised RN A to call the family and ask if they wanted a portable X-ray or have the resident sent to the emergency room. The family chose to have Resident #1 sent to the emergency room at that time. RN A notified emergency medical services for a transfer. The Administrator said any time any resident is in the floor, she expected staff to assess the resident, document the situation and notify the physician and family. The Administrator said she considered this incident to be a fall and should have been treated as one. The Administrator said RN B should have investigated and assessed the resident's pain when the resident was still in the floor. The physician should have been called for further instruction at that time as well. The Administrator said when she arrived at work on [DATE] she was notified the resident had experienced a behavior, but was not informed of any potential injuries. The Administrator said, after she got to the facility she was scheduled to go shopping for residents. Had she known the resident had any complaints of pain, or that he/she had dropped to the floor, she would have gone and assessed the resident immediately. RN A or RN B could have contacted her at any time prior to her return to the facility and she would have come back or giving direction to contact the doctor. The Administrator said she expected the licensed staff, including RN A and RN B to call a resident's family, a resident's physician and/or emergency services without her consent.
During an interview on [DATE] at 4:10 P.M., the Primary Care Physician (PCP) said he/she would have expected the staff to fully assess resident #1 after a fall regardless of putting self in floor or not and to notify him/herself of the incident in a timely manner. The PCP said they should have given the resident at least Tylenol for pain after such an event and definitely would have been expected to be notified immediately when assessed to have a rotation in the lower extremities indicating a fracture which is very painful.
Complaint #MO218205
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and treat one resident (Resident #1) of three sampled reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and treat one resident (Resident #1) of three sampled residents, in a timely manner after Resident #1 fell to to the floor on [DATE]. The fall occurred at 4:00 A.M., at 6:30 A.M., a nurse noted the resident was in pain and had marked rotation to the right leg, no interventions for pain or post fall procedures were put in place until seven hours later at 1:30 P.M., when the resident was sent to the hospital. Resident #1 was diagnosed with a displaced right hip fracture. The facility census was 41.
The facility did not provide a policy regarding falls, post fall assessment or pain managment.
1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated [DATE] showed:
- admission to facility on [DATE];
- Diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, the disease involves parts of the brain that control thought, memory, and language), dementia with behavioral disturbances (Behavioral disturbances in dementia are often globally described as agitation including verbal and physical aggression, excessive wandering, and sleep disturbance), anxiety, major depressive disorder (Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living), lack of coordination (lost of balance);
- Cognition impaired;
- Delirium with fluctuating behaviors of inattention and disorganized thinking, comes and goes and changes in severity;
- Requires supervision of one staff member for exiting secure unit;
- Guardian in place.
Review of the resident Care Plan, showed:
- At risk for falls related to diagnosis of Alzheimer's and overestimates abilities at times;
- The resident has difficulty making safe decisions related to a history of dementia;
The Care Plan did not address pain or pain management.
Review of the [DATE] Physician Order Sheet (POS), showed:
- No order for pain/fever reducing medications;
- No order to send resident to emergency room for evaluation.
Review of the progress notes showed:
- On [DATE] at 4:10 A.M., Resident #1 threw self into floor and started screaming and hollering for help and saying she hit me, staff assisted the resident back to his/her room, will continue to monitor;
- On [DATE] at 2:06 P.M., the resident complained of severe pain to the right pelvic area due to a fall this morning. Contacted the resident Power of Attorney (POA) (a legal document allowing a person to act on your behalf), ambulance responded to facility to transport resident to hospital.
Review of Resident #1 hospital report dated [DATE] through [DATE] showed:
- Resident #1 admitted with displaced right hip fracture;
- Resident expired on [DATE] with cause of death listed as Alzheimer's disease and right hip fracture.
The facility did not provide any investigation of the fall, post fall or pain assessment of the resident.
During a interview on [DATE] at 10:45 A.M., Registered Nurse (RN) A said on [DATE] during shift report, the previous nurse, RN B, did not give any report on Resident #1's behaviors or changes in condition. RN A said his/her shift began as usual, going to the special care unit at approximately 6:30 A.M. Upon entering the unit a staff member informed him/her Resident #1 had thrown him/herself in the floor on the prior shift. RN A said he/she went to the resident's room to assess and found the resident's right leg bent at the knee with rotation (indicating a fracture). The resident cried out in pain when touching the knee/pelvic/hip area. RN A said he/she was surprised the night shift nurse did not notice the rotation in the right leg due to it was very obvious. RN A said he/she did not notify the physician or family, and did not administer any pain medications to the resident. RN A said he/she waited for the Administrator to come to work and assess the resident. At approximately 1:30 P.M. (seven hours later) the Administrator came in and they both decided to notify the family and call an ambulance to transfer the resident to the emergency room. RN A said time got away from him/her with other duties and the Administrator had left the building, so he/she did not remember to inform her (administrator) he/she needed her to look at Resident #1 until later that afternoon. When asked if the resident was in pain that entire time, RN A did not respond. When asked why no pain medications were administered upon the initial observation of the injury, RN A did not respond. When asked why the doctor and family were not contacted upon discovery, RN A did not respond.
During an interview on [DATE] at 1:25 P.M., Certified Nurse Aide (CNA) C said he/she was working the special needs unit during the night shift on [DATE]. At approximately 4:00 A.M., CNA C went to the employee rest room on the unit. When CNA C came out, Resident #1 was standing at the door attempting to get past him/her to get into the bathroom. CNA C said he/she tried to assist the resident to turn around when the resident suddenly went to the floor, landed on his/her knees, screamed and slapped the floor and rolled around. RN B heard the commotion and came onto the unit along with CNA D. RN B checked the resident's vital signs while the resident was holding his/her right knee. RN B directed CNA C and CNA D to get the resident off the floor and assist Resident #1 to his/her room. The resident limped on the right leg from where he/she fell to his/her room at the opposite end of the hall. The resident then remained in his/her room screaming for an unknown person and her spouse. No other interventions were done that he/she is aware of. CNA C said Resident #1 had been limping prior to the fall due to a blister on the right foot, but had not appeared to be in the extreme pain he/she was exhibiting after the incident.
During an interview on [DATE] at 2:35 P.M., CNA D said RN B ask him/her to assist on the special needs unit on [DATE] to help in get Resident #1 off the floor. Upon entering the unit CNA D observed Resident #1 on the floor on his/her left side crying out and asking for his/her spouse. When RN B attempted to move the residents right leg Resident #1 screamed out with pain, the staff attempted to get the resident to sit in a wheelchair but he/she refused so he/she and CNA C walked Resident #1 to his/her room while the resident limped and cried. CNA D said the resident was in obviously in a great deal of pain.
During a telephone interview on [DATE] at 2:45 P.M., RN B said CNA C had called him/her to the unit saying Resident #1 put him/herself on the floor. Upon arrival, RN B saw Resident #1 on the floor yelling she pushed me and broke my leg referring to CNA C. The resident was holding his/her right leg. RN B said he/she knew Resident #1 had previously had a blister on his/her right foot, and thought that was why he/she held the right leg. The staff assisted the resident to his/her room. The resident limped and cried during the walk to his/her room. The resident continued to cry as staff assisted him/her to lay on the bed. RN B said he/she looked at the resident legs and did not notice any deformities. RN B said he/she asked the resident if he/she was in pain and the resident would point at his/her lower leg. RN B said he/she went back about an hour later and the resident was still crying and yelling out for his/her spouse. At that time the he/she administered a antianxiety medication to calm the resident. RN B said he/she gave the resident antianxiety medication because he/she felt like the resident denied having pain. When asked why no pain medications were given when the resident indicated her leg hurt during the initial incident, RN B did not answer. When asked why after waiting an hour and finding the resident still crying, no pain medications were given or pain assessment completed, RN B did not answer. When asked what the facility's policy for post fall assessment was, RN B said he/she did not consider the resident dropping to the floor a fall, he/she felt it was a behavior.
During an interview on [DATE] at 3:15 P.M., the Administrator said on [DATE] at 1:30 P.M., RN A notified her of Resident #1 having thrown him/herself in the floor during the night shift and had visible rotation on the right lower leg. She accompanied RN A and assessed the resident. Resident #1 had rotation noted on the right leg. She then advised RN A to call the family and ask if they wanted a portable X-ray or have the resident sent to the emergency room. The family chose to have Resident #1 sent to the emergency room at that time. RN A notified emergency medical services for a transfer. The Administrator said she would have expected the staff to assess the resident, document any incident of the resident being in the floor, and notify the physician and family. The Administrator said she considered this incident to be a fall and should have been treated as one. The Administrator said when she arrived at work on [DATE] she was notified the resident had experienced a behavior, but was not informed of any potential injuries. The Administrator said, had she known of any injury or complaints of pain she would have assessed the resident immediately.
During an interview on [DATE] at 4:10 P.M., the Primary Care Physician (PCP) said he/she would have expected the staff to fully assess resident #1 after a fall regardless of putting self in floor or not and to notify him/herself of the incident in a timely manner. The PCP said it would be difficult to evaluate pain in Resident #1 but the staff should have given the resident tat least Tylenol for pain after such an event and definitely would have been expected to be notified immediately when assessed to have a rotation in the lower extremities indicating a fracture which is very painful.
Complaint #MO218205
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 interview and record review, the facility failed to notify a resident's family and physician after a fall with injury in a timely manner for one (Resident #1) of three sampled residents at ri...
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Based on interview and record review, the facility failed to notify a resident's family and physician after a fall with injury in a timely manner for one (Resident #1) of three sampled residents at risk for falls. The facility census was 41.
The facility did not provide a policy regarding notifications.
1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 3/16/2023 showed:
- admission to facility on 06/06/2022;
- Diagnoses of Alzheimer's disease ( a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, the disease involves parts of the brain that control thought, memory, and language), dementia with behavioral disturbances (Behavioral disturbances in dementia are often globally described as agitation including verbal and physical aggression, excessive wandering, and sleep disturbance), anxiety, major depressive disorder (Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living), lack of coordination (lost of balance);
- Cognition impaired;
- Delirium with fluctuating behaviors of inattention and disorganized thinking, comes and goes and changes in severity;
- Requires supervision of one staff member for exiting secure unit;
- Guardian in place.
Review of the resident Care Plan, showed:
- At risk for falls related to diagnosis of Alzheimer's and overestimates abilities at times;
- Resident resides on the special care unit due to diagnosis of Alzheimer's;
- The resident has difficulty making safe decisions related to a history of dementia;
- Power of Attorney (POA) (a legal document allowing a person to act on your behalf)
Review of the progress notes showed:
- On 04/28/2023 at 4:10 A.M., resident entering other resident rooms, when told not to enter the room resident becomes combative with the staff and attempts to hit staff. The resident then threw self into floor and started screaming and hollering for help and saying she hit me, staff wheeled the resident back to his/her room, will continue to monitor;
- On 04/28/2023 at 2:06 P.M., (10 hours after the incident) the resident complained of severe pain to the right pelvic area due to a fall this morning. Contacted the resident POA, ambulance responding to facility to transport resident to hospital;
- No record of notification of the physician.
During a interview on 05/17/2023 at 10:45 A.M., Registered Nurse (RN) A said on 04/28/2023 a staff member informed him/her Resident #1 had thrown him/herself in the floor. RN A said he/she assessed the resident and observed the right leg bent at the knee with rotation (indicating a fracture). The resident cried out in pain when touching the knee/pelvic/hip area. RN A said he/she did not notify the physician or family at that time, but wanted to wait for the Administrator to come to work and let her assess the resident. At 1:30 P.M., RN A took the Administrator to assess Resident #1. At that time, the family and emergency services was notified by another nurse.
During a telephone interview on 05/17/2023 at 2:45 P.M., RN B said CNA C had called him/her to the unit stating Resident #1 put him/herself on the floor. Upon arrival he/she saw Resident #1 on the floor yelling she pushed me and broke my leg referring to CNA C. The resident was holding his/her right leg but at that time he/she thought it was due to a blister the resident had on the right foot. The staff attempted to assist the resident to walk as the resident limped on the right leg, again he/she believed it was due to the blister and the resident had been limping in such a way for the past few days. The resident continued to cry as staff assisted him/her to lay on the bed. RN B stated she looked at the resident legs and did not notice any deformities, when asking the resident if he/she was in pain the resident would point at his/her lower leg. RN B said he/she went back about an hour later and the resident was still crying and yelling out for his/her spouse. At that time the he/she administered a antianxiety medication to calm the resident. RN B did not notify the facility administration, family or physician.
During an interview on 05/17/2023 at 3:15 P.M., the Administrator said on 04/28/2023 at 1:30 P.M., RN A notified her of Resident #1 having thrown him/herself in the floor during the night shift and had visible rotation on the right lower leg. She accompanied RN A and assessed the resident. Resident #1 had rotation noted on the right leg. She then advised RN A to call the family and ask if they wanted a portable X-ray or have the resident sent to the emergency room. The family chose to have Resident #1 sent to the emergency room at that time. RN A notified emergency medical services for a transfer. The Administrator said any time any resident is in the floor, she expected staff to assess the resident, document the situation and notify the physician and family. The Administrator said she considered this incident to be a fall and should have been treated as one. The Administrator said RN B should have investigated and assessed the resident's pain when the resident was still in the floor. The physician should have been called for further instruction at that time as well. The Administrator said she expected the licensed staff, including RN A and RN B to call a resident's family, a resident's physician and/or emergency services without her consent.
During an interview on 05/18/2023 at 4:10 P.M., the Primary Care Physician (PCP) said he/she would have expected the staff to fully assess Resident #1 after a fall and to notify him/her of the incident in a timely manner.
Complaint #MO218205
Jun 2021
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the dignity of one resident (Resident #189) ou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the dignity of one resident (Resident #189) out of 15 sampled residents, and one additional resident (Resident #1) outside the sample. The facility census was 39.
1. Review of Resident #1's medical chart, showed:
- Resident admitted on [DATE];
- Resident needs extensive assistance of one staff for grooming and hygiene.
Observations of the resident showed:
- On 6/22/21 at 12:46 P.M., a large area of long facial hair on his/her chin;
- On 6/23/21 at 7:57 P.M., a large area of long facial hair on his/her chin;
- On 6/24/21 at 10:25 A.M., the resident was pushed outside to visit with his/her family member with a large area of facial hair on his/her chin, hair uncombed.
During an interview on 6/24/21 at 10:30 A.M., the residents family member said the resident was brought out for a visit with sticky hands and face, uncombed hair, and food on the lap blanket. The family member said they were concerned about the resident's care due to the condition the resident was brought out for a family visit.
Observations of Resident #1 on 6/24/21 at 10:30 AM showed food particles on lap blanket and on the ground where they had fallen when the lap blanket was removed, a large area of facial hair on the chin and uncombed hair.
During an interview on 6/24/21 at 11:05 A.M., the Director of Nursing (DON) said she would expect staff to wash a residents face and hands before and after meals and make sure they didn't have food on their clothing or blankets. Hair should be combed and facial hair should be removed as needed, these things should be done regardless of whether they are going out to family visits or not.
During an interview on 6/25/21 at 11:15 A.M., Certified Nurse Aide (CNA) C said chin hairs should be removed with showers, hands and faces should be washed before and after meals, and clothes should be changed after meals if they have food on them.
2. Review of Resident #189's medical chart showed:
- Resident admitted on [DATE];
- Diagnosis of Dementia;
- Resident needs assistance of one staff for grooming and hygiene.
Observations of the resident on 6/22/21 through 6/25/21 showed:
- The resident had long facial hair on his/her chin throughout the survey;
- On 6/22/21 at 2:00 P.M., resident visited with family in an area outside the building with long facial hair on his/her chin;
- On 6/25/21 at 8:37 A.M. resident had on a light colored sweatshirt that he/she had worn two days earlier. The sweatshirt had five quarter sized and larger dried coffee stains down the front. Resident said it was from when he/she spilled coffee.
During an interview on 6/25/21 at 8:40 A.M., CNA F said the resident was already dressed when his/her shift started, and the resident should not be wearing a dirty shirt. CNA F said they usually shave chin hair during showers, if needed.
Review of the facility's Resident Rights policy, not dated, showed:
- Our residents will always be provided with the highest level of care and service;
- The policy did not specifically address proper grooming of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the accuracy of the advance directives (a written statement o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the accuracy of the advance directives (a written statement of a person's wishes regarding medical treatment) regarding the resuscitation status for two residents (Resident #35 and #187) out of 15 sampled residents and one resident (Resident #137) outside the sample. The facility census was 39.
Record review of the facility's policy on Advance Directives, undated showed:
- Upon admission of a resident to the facility, the social service designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical surgical treatment and the right to formulate an advance directive.
- The social service designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directive.
- Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab.
1. Record review of Resident #35's Physician Order Sheet (POS), dated June 2021, showed an order for full code status (allow all interventions needed to restart the heart).
Record review of the resident's medical record showed:
- Face Sheet Advance Directive, DNR (Do Not Resuscitate, do not allow any interventions to restart heart);
- Care plan, last revised on 6/2/21, showed the resident as DNR status.
2. Record review of Resident #137's medical record showed:
- admitted to facility on 6/18/21;
- The POS, dated June 2021, did not show a code status (resuscitation status) for the resident;
- The Interim Care Plan, dated 6/18/2021, did not address code status;
- Face Sheet located in front of medical chart, did not show a code status for the resident;
- No Advance Directives or code status located in Resident's medical chart.
3. Record review of Resident #187's Physician Order Sheet (POS), dated June 2021, showed an order for Full Code status.
Record review of the resident's medical record showed:
- Resident admitted [DATE];
- Face Sheet Advance Directive, DNR;
- Care plan, last revised on 6/22/21, showed the resident as DNR status.
During an interview on 6/25/2021 at 10:00 A.M., Licensed Practical Nurse (LPN) E said if a resident codes, staff looks at the electronic medical record on the computer or the resident information binder at the nurses station to see what the code status is. If the information on the computer is conflicting, then the resident is treated by what code status shows in the resident information binder at the Nurse's Station.
During an interview on 6/24/21 at 3:20 P.M. the Director of Nursing (DON) said the binder at the nurse's station is kept up to date. The staff should go to the binder first if there should be a code. She said it could take too long to get on the computer and look in the chart. She said if there is no code status listed on a resident then staff would need to treat the resident as a full code status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to maintain a safe, clean, comfortable and homelike environment. This practice affected two residents (Resident #12 and #33) out of 15 sampled re...
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Based on observation and interview the facility failed to maintain a safe, clean, comfortable and homelike environment. This practice affected two residents (Resident #12 and #33) out of 15 sampled residents and one resident (Resident #1) outside the sample. The facility census was 39.
The facility did not provide a policy or procedure regarding environmental maintenance.
1. Observation on 6/22/21 at 11:03 A.M., of Resident #1 showed:
- Right arm rest of the wheel chair with cracked vinyl across the top surface of the arm rest and vinyl peeling along the inner edge;
- Wheelchair seat with cracked vinyl across the front edge.
2. Observation on 6/22/21 at 11:03 A.M., of Resident #12 showed:
- Left arm rest of the wheelchair with 5 inches of cracked vinyl across top surface to the middle portion of the arm rest;
- Right arm rest of the wheelchair with 3 inches of cracked vinyl across the back portion of the arm rest .
3. Observation on 6/25/21 at 9:20 A.M. of Resident #33 showed:
- Left arm rest of the wheelchair with a half inch by two inch tear to the outer area;
- Right arm rest of the wheelchair tattered with numerous tears throughout the arm.
During an interview on 6/25/21 at 10:50 A.M. the Director of Nursing (DON) said the facility does not have a policy on the environment. She said any staff can fill out a repair form and place it in the maintenance staff box. She said she knew there were some concerns with a few wheelchairs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to assess the use of chair and bed alarms to determine if they were a restraint, failed to document the alarms on one resident's...
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Based on observation, interview, and record review, the facility failed to assess the use of chair and bed alarms to determine if they were a restraint, failed to document the alarms on one resident's (Resident #16) care plan, failed to identify a medical symptom that supported the use of the alarms, failed to document the least restrictive use for the alarms, failed to document an ongoing re-evaluation for the use of the alarms, for four residents (Resident #2, #3, #16, and #35) out of 15 sampled residents and one resident (Resident #7) outside the sample. The facility census was 39.
1. Record review of the Resident #2's June 2021 Physician Order Sheet (POS), showed:
- No order for a chair and bed alarm.
Record review of the resident's medical record showed:
- No assessment for the chair and bed alarm to determine if used as a restraint;
- No documentation of the least restrictive use for the chair and bed alarm;
- No documentation of ongoing re-evaluations for the use of the chair and bed alarm.
Observations of resident #2 showed:
- On 6/22/21 at 12:10 P.M., resident lay in bed before lunch, bed alarm in place under resident;
- On 6/23/21 at 5:45 P.M., chair alarm in place on back of resident's wheelchair while eating supper.
Record review of the resident's care plan, dated 2/13/21 showed:
- Monitor alarm use for efficacy and make changes if and when needed;
- Monitor for adverse consequences of alarm use, including, but not limited to fear, anxiety, or agitation related to the alarm sound, decreases mobility, sleep disturbances, and infringement on freedom of movement, dignity, and privacy;
- Monitor use of alarms and adjust care plan as needed.
During an interview on 6/22/21 at 12:10 P.M., Certified Nurse Aide (CNA) G said the resident has a bed and chair alarm because he/she tries to transfer self, has a history of falls, and he/she is wearing a elbow brace due to a previous fall.
2. Record review of Resident #3's June 2021 POS, showed:
- No order for a chair or bed alarm.
Record review of the resident's medical record showed:
- No documentation of monitoring or medical reason for use of the bed alarm;
- No assessment for the bed alarm to determine if used as a restraint;
- No documentation of the least restrictive use for the bed alarm;
- No documentation of ongoing re-evaluations for the use of the bed alarm.
Observations of Resident #3 showed:
- On 6/22/21 at 11:00 A.M., chair alarm in place, attached to the resident's wheelchair and his/her shirt;
- On 6/23/21 at 10:13 A.M., chair alarm in place, attached to the resident's wheelchair and his/her shirt;
- On 6/24/21 at 11:37 A.M., chair alarm in place, attached to the resident's wheelchair and his/her shirt.
Record review of the resident's care plan, dated 5/28/21 showed:
- Monitor alarm use for efficacy and make changes if and when needed;
- Monitor for adverse consequences of alarm use, including, but not limited to fear, anxiety, or agitation related to the alarm sound, decreases mobility, sleep disturbances, and infringement on freedom of movement, dignity, and privacy;
- Monitor use of alarms and adjust care plan as needed.
During an interview on 6/25/21 at 10:52 A.M., CNA B said the resident does have a bed and chair alarm because he/she tries to transfer self.
During an interview on 6/24/21 at 5:15 P.M. the Director of Nursing (DON) said the chair/bed alarm was placed on the resident on 2/16/21 and no assessments completed.
3. Record review of Resident #7's June 2021 POS, showed:
- No order for chair alarm.
Record review of the resident's medical record showed:
- No documentation of monitoring or medical reason for use;
- No assessment for the bed alarm to determine if used as a restraint;
- No documentation of the least restrictive use for the bed alarm;
- No documentation of ongoing re-evaluations for the use of the bed alarm.
Observations of Resident #7, showed:
- On 6/22/21 at 10:27 A.M., chair alarm in place, attached to the resident's wheelchair and his/her shirt;
- On 6/23/21 at 1:45 P.M., chair alarm in place, attached to the resident's wheelchair and his/her shirt;
- On 6/25/21 at 10:58 A.M., chair alarm in place, attached to the resident's wheelchair and his/her shirt.
Record review of the resident's care plan, dated 6/16/21 showed:
- Monitor alarm use for efficacy and make changes if and when needed;
- Monitor for adverse consequences of alarm use, including, but not limited to fear, anxiety, or agitation related to the alarm sound, decreases mobility, sleep disturbances, and infringement on freedom of movement, dignity, and privacy;
- Monitor use of alarms and adjust care plan as needed.
During an interview on 6/25/21 at 10:55 A.M., CNA B said the resident has a chair alarm due to falls and trying to transfer self. If he/she doesn't have one on it is probably because he/she disposed of it, that is done often.
During an interview on 6/24/21 at 5:17 P.M. the DON said the chair alarm was placed on the resident on 1/24/21 and no assessments completed. She said the resident is at high risk for falls.
4. Record review of Resident #16's June 2021 POS, showed:
- No order for bed alarm.
Record review of the resident's medical record showed:
- No documentation of monitoring or medical reason for use
- No assessment for the bed alarm to determine if used as a restraint;
- No documentation of the least restrictive use for the bed alarm;
- No documentation of ongoing re-evaluations for the use of the bed alarm;
- No care plan addressing bed alarm.
Observations of Resident #16, showed:
- On 6/22/21 at 11:09 A.M., bed alarm in place under resident;
- On 6/22/21 at 12:09 P.M., bed alarm in place under resident;
- On 6/24/21 at 1:45 P.M., bed alarm in place under resident.
During an interview on 6/25/21 at 10:59 A.M., CNA B said the resident has a bed alarm because she use to try to get out of bed often, but lately she just tries to get up every now and then, not too often.
During an interview on 6/24/21 at 5:19 P.M., the DON said the bed alarm was placed on the resident on 3/25/21 and no assessments completed.
5. Record review of Resident #35's June 2021 POS, showed:
- No order for chair alarm.
Observations of the resident showed:
- On 6/22/21 at 12:15 P.M., chair alarm in place, attached to the resident's wheelchair and his/her shirt;
- On 6/23/21 at 8:00 A.M., and 12:20 P.M., and 5:30 P.M. chair alarm in place, attached to the resident's wheelchair and his/her shirt;
- On 6/24/21 at 7:50 A.M., 8:45 A.M., 12:15 P.M., and 5:10 P.M. chair alarm in place, attached to the resident's wheelchair and his/her shirt;
- On 6/25/21 at 8:12 A.M., chair alarm in place, attached to the resident's wheelchair and his/her shirt.
Record review of the resident's medical record showed:
- No documentation of monitoring or medical reason for use
- No assessment for the bed alarm to determine if used as a restraint;
- No documentation of the least restrictive use for the bed alarm;
- No documentation of ongoing re-evaluations for the use of the bed alarm.
Record review of the resident's care plan, dated 6/2/21 showed:
- Monitor alarm use for efficacy and make changes if and when needed;
- Monitor for adverse consequences of alarm use, including, but not limited to fear, anxiety, or agitation related to the alarm sound, decreases mobility, sleep disturbances, and infringement on freedom of movement, dignity, and privacy;
- Monitor use of alarms and adjust care plan as needed;
- No indication as to what the underlying problem is for the use of the bed and chair alarms.
During an interview on 6/24/21 at 8:40 A.M., CNA B said the resident tries to get up at times and has had some falls.
During an interview on 6/24/21 at 5:20 P.M., the DON said the chair alarm was placed on the resident in July 2019 and no assessments completed.
During an interview on 06/25/21 at 3:00 P.M., the DON said they do not do assessments for chair or bed alarms, and she was not sure if they needed a doctor's order but thought it was a nursing judgement.
Record review of the facility's policy on Use of Restraints, undated showed:
- Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully.
- Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls.
- Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the the problematic medical symptoms and to determine if there are less restrictive interventions that may improve the symptoms.
- Restraints shall only be used upon the written order of a physician and after informing the resident and/or legal representative and should include the medical reason for the restraint, how it will be used to benefit the resident's medical symptom, the type of restraint, and period of time for the use of the restraint.
- Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom, but the underlying problems that may be causing the symptoms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to correctly mark a Minimum Data Set (MDS), a federally ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to correctly mark a Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff for two residents (Resident #2 and #35) out of 15 sampled residents. The facility census was 39.
1. Record review of Resident #2's MDS, dated [DATE], not marked for chair and bed alarms.
Observations of Resident #2 showed:
- On 6/22/21 at 12:10 P.M., resident laid in bed before lunch, bed alarm in place under resident, hinged elbow brace on left arm ;
- On 6/23/21 at 5:45 P.M., chair alarm in place on back of resident's wheelchair while he/she is eating supper;
Record review of the resident's care plan, dated 2/13/21 showed:
- Monitor alarm use for efficacy and make changes if and when needed;
- Monitor for adverse consequences of alarm use, including, but not limited to fear, anxiety, or agitation related to the alarm sound, decreases mobility, sleep disturbances, and infringement on freedom of movement, dignity, and privacy;
- Monitor use of alarms and adjust care plan as needed.
During an interview on 6/22/21 at 12:10 P.M., Certified Nurse Aide (CNA) G said the resident does have a bed and chair alarm both because he/she tries to transfer self, and has a history of falls, and he/she is wearing the elbow brace due to a previous fall.
2. Record review of Resident #35's annual MDS, dated [DATE], not marked for chair alarm.
Observations from 6/22/21 through 6/25/21 at breakfast and lunch meals, the alarm in place on the resident's wheelchair and to the resident's shirt.
Observation on 6/24/21 at 8:45 A.M. prior to transfer, the alarm in place on the wheelchair and clipped to the back of the resident's shirt.
Observation on 6/25/21 at 8:12 A.M. the resident sat in his/her room with alarm on his/her wheelchair and clipped to his/her shirt.
During an interview on 6/23/21 at 5:20 P.M. the Director of Nursing (DON) said she just missed it on the MDS, the resident has had the chair alarm for a long time since he/she fell and broke his/her hip. The DON said the chair alarm had been on the resident since July 2019.
During an interview on 6/25/21 at 3:00 P.M., the DON said they do not do assessments on chair or bed alarms. She would expect it to be marked correctly on the resident's MDS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement comprehensive care plans with specific interventions tailored to meet individual needs for two residents (Resident #3...
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Based on interview and record review, the facility failed to develop and implement comprehensive care plans with specific interventions tailored to meet individual needs for two residents (Resident #3, and #16) out of 15 sampled residents. The facility census was 39.
1. Record review of Resident #3's Physician Order Sheet (POS), dated 6/1/21 - 6/24/21, showed:
- Diagnoses of Dysphagia (Difficulty swallowing);
- An order for SB6 diet (soft, tender and moist throughout, with no seperated thin liquid) gravy with ground meat, start date 3/10/21.
Review of the resident's nutrition notes dated 4/19/21, showed:
- The resident saw a dentist on 4/19/21;
- The resident has has 6 bottom teeth that are non-restorable;
- The resident and family decided to leave them alone unless they become painful or start causing problems.
Review of the resident's Care Plan dated 5/28/21, showed:
- No interventions for dysphagia or diet order;
- No interventions for dental concerns.
During an interview on 6/25/21 at 11:20 A.M., the Director of Nursing (DON) said she would expect the care plan to address all concerns including diet and dental concerns.
2. Record review of Resident #12's therapy discharge documentation, showed:
- On 5/17/21, discharge from Occupational Therapy (OT) services with recommendations for Restorative Nursing Program to be established to enable the resident to maintain gains made in therapy;
- On 5/10/21, discharge from Physical Therapy (PT) services with recommendations for Restorative Nursing Program to be established to enable the resident to maintain gains made in therapy.
3. Observations of Resident #16, showed:
- On 6/22/21 at 11:09 A.M., bed alarm in use;
- On 6/22/21 at 12:09 P.M., bed alarm in use;
- On 6/24/21 at 1:45 P.M., bed alarm in use.
Review of the resident's Care Plan, showed it did not address the use of a bed alarm.
During an interview on 6/25/21 at 10:59 A.M., CNA B said the resident does have a bed alarm because she use to try to get out of bed often, but lately she just tries to get up every now and then, not too often.
During an interview on 6/25/21 at 11:20 A.M., the DON said alarms should be addressed on the care plan when in use.
Record review of the facility's policy on Care Plan Comprehensive, undated, showed:
- An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being.
- Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition.
- The interdisciplinary care plan team is responsible for the periodic review and updating of care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide care and services for activities of daily living (such as bathing) for three residents (Resident #28, #31, and #35) o...
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Based on observation, interview, and record review, the facility failed to provide care and services for activities of daily living (such as bathing) for three residents (Resident #28, #31, and #35) out of 15 sampled residents and two residents (Resident #7 and #27) outside the sample. This practice could potentially affect all residents. The facility census was 39.
1. The facility did not provide an Activities of Daily Living policy.
2. Record review of Resident #7's April, May, and June, shower sheets on the 100 hall showed:
- No showers documented for April;
- One shower documented on 5/3/21;
- One shower documented on 6/21/21.
During an interview on 6/23/21 at 10:41 A.M., the resident said, he/she use to get 2-3 showers a week. Now only one a week and sometimes it is 2 weeks or so in between showers. He/she would like to have more showers.
3. Observations from 6/22/21 through 6/25/21 showed Resident #27's hair combed straight back each day with a dirty and oily appearance.
4. Record review of Resident #28's April, May and June, shower sheets on the 100 hall showed:
- Resident admitted to facility on 4/23/21;
- No documentation for showers for April;
- One shower documented on 5/3/21;
- No documentation for showers for June.
During an interview on 6/23/21 at 6:14 P.M. the resident said, he/she has had one shower since admission. The resident said, I go to the beauty shop to get my hair washed.
5. Record review of Resident #31's April, May, and June, shower sheets on the 300 hall showed:
- Showers documented 4/7/21 and 4/21/21;
- No documentation for showers for May;
- Showers documented 6/2/21 and 6/17/21.
Observations from 6/22/21 through 6/25/21 showed:
- The residents hair not clean;
- The residents nails long, dirty with debris under the nails.
During an interview on 6/23/21 at 1:51 P.M. the resident said, he/she had not had a shower in nine days he/she thought. The resident said his/her hair is dirty and needs a shower.
During an interview on 6/23/21 at 2:30 P.M. the Director of Nursing (DON) said the resident will refuse nail care and showers occasionally.
During an interview on 6/25/21 at 9:50 A.M. Certified Nurse Aide (CNA) B said the resident will at times refuse a shower, then later in the day will decide to get one. The CNA said if any resident refuses a shower then other staff can ask, if they refuse then it should be reported to the charge nurse or DON.
6. Record review of Resident #35's April, May, and June, shower sheets on the 300 hall showed:
- No documented showers for April or May;
- Showers documented 6/21/21.
During an interview on 6/25/21 at 11:15 A.M., CNA C said the resident should get showers two times a week but at times it is longer than weekly between showers, sometimes it is due to staffing and sometimes they refuse.
During an interview on 6/22/21 at 1:03 P.M., CNA G said Resident #27 lives on the Dementia Unit. CNA G said he/she works on the Dementia Unit by herself most days. CNA G said he/she is not able to give showers during his/her shift because that would leave the other residents unattended. The facility does not have shower aides, so the CNAs are responsible to bathe the residents on their hall. CNA G said he/she tries to give the residents on the Unit a quick bedside bath in place of a shower, so that he/she can still hear what is going on with the other residents on the hall.
The facility did not provide a policy on showers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide proper personal hygiene during toileting for t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide proper personal hygiene during toileting for two residents (Resident #3 and #187) out of seven sampled residents, and one resident (Resident #1) outside the sample. The facility census was 39.
1. Record review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/23/21 showed:
- Occasionally incontinent of urine, always continent of bowel;
- Extensive assist of one staff for transfer;
- Extensive assist of one staff for toileting;
- Extensive assist of one staff for personal hygiene.
Observation on 6/24/21 at 10:15 A.M., showed;
- Certified Nursing Assistant (CNA) B assisted Resident #1 to standing position after toileting;
- The resident stood holding on to the grab bar;
- CNA B cleaned the resident's rectal area of a small smear of fecal matter;
- CNA B reached between resident's legs and wiped from the rectal area with an upward motion to the front peri-area wearing the same soiled gloves
- CNA B placed a clean brief and pulled the resident's pants up wearing the soiled gloves
- CNA B failed to change gloves while providing care.
2. Record review of Resident #3's admission MDS, dated [DATE], showed:
- Always continent of bowel and bladder;
- Limited assist of one staff for transfers;
- Limited assist of one staff for toileting;
- Supervision and set up for personal hygiene.
Observations on 6/24/21 at 11:37 A.M., showed:
- CNA B assisted Resident #3 to standing position after toileting;
- The resident stood holding on to the grab bar;
- CNA B reached between resident's legs and wiped from the rectal area with an upward motion to the front peri-area.
3. Record review of Resident #187's Baseline Care Plan, dated 6/15/21, showed:
- Sometimes incontinent of bowel;
- Sometimes incontinent of bladder;
- Assist of one staff for toileting;
- Assist of two staff for transfers;
- Resident is unable to manage own toileting functions and requires all cares to be provided by staff;
- Resident will receive cares necessary to maintain hygiene, promote dignity, and avoid skin breakdown.
Observation of the resident on 6/24/21 at 2:00 P.M., showed:
- Resident laid in bed;
- CNA A and CNA B washed hands and donned gloves;
- CNA B removed incontinent brief soiled with urine from resident;
- CNA B wiped down resident's front center peri-area with wet cloth;
- CNA A rolled resident over on his/her right side;
- Resident had a wound dressing over his/her coccyx area;
- CNA B wiped resident's rectal area in an upward direction;
- CNA B did not wipe the resident's hips on either side;
- With the same soiled gloves, CNA B placed a clean incontinent brief under the resident;
- With the same soiled gloves, CNA B put her hands on the resident's left shoulder and hip and rolled him/her over on his/her back;
- With the same soiled gloves, CNA B pulled the resident's gown down over his/her lower torso, and pulled a clean sheet up to his/her chest;
- CNA B did not change gloves until he/she was finished providing care to the resident;
During an interview on 6/24/21 at 2:30 P.M. CNA B said he/she should have cleaned from front to back when providing care and gloves should be changed after care, when the gloves become contaminated.
During an interview on 6/25/21 at 11:15 A.M., CNA C said gloves should be changed when they are soiled, with additional care, or when going from dirty to clean and resident should be cleaned from the front to the back.
During an interview on 6/25/21 at 11:20 A.M., the Director of Nursing (DON) said she would expect proper technique when providing peri-care to the residents, and she would expect staff to change gloves when going from dirty to clean or different areas.
Record review of the facility's Perineal Care procedure guide, not dated, showed:
- Purpose is to cleanse the perinium, and prevent infection and odor;
- Put on disposable gloves;
- Use wet washcloth with light amount of soap;
- Wash from front to back;
- Remove gloves and wash hands;
- Replace blanket and spread;
- Position resident comfortably with call light within reach.
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 program of activities designed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This practice affected five residents (Resident #7, #10, #26, #28, and #31) out of 15 sampled residents and could potentially affect all residents. The facility census was 39 .
1. Record review of the June 2021 calendar showed no activities scheduled for any unit in the facility
Interviews with residents showed:
- On 6/23/21 at 2:37 P.M., Resident #26 said the facility did not have an Activity Director (AD) at this time, he/she does enjoy some activities and attends at times;
- On 6/23/21 at 3:12 P.M. Resident #28 said he/she hardly ever sees activities going on;
- On 6/23/21 at 4:51 P.M. Resident #31 said the facility does not have an AD at this time, and he/she would attend activities especially the singing. The resident said he/she really enjoys gospel music.
- On 6/23/21 at 5:25 P.M. Resident #7 said he/she likes Bingo, but there hasn't been much of it lately.
2. Record review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/14/20 showed:
- All activities important to the resident;
- Available reading material, music, favorite activities and group activities very important.
3. Record review of Resident #26's Annual MDS, dated [DATE] showed:
- All activities important to the resident;
- Available reading material, music, favorite activities, group activities and religious activities very important to the resident.
4. Record review of Resident #28's Annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/28/21 showed:
- Favorite activities, group activities, and religious activities important to the resident;
- Going outside in good weather very important to the resident.
5. Record review of Resident #31's admission MDS dated [DATE], showed groups of people somewhat important, fresh air somewhat important, and very important on religious services.
6. Observations of the Dementia Unit during the survey dates 6/22/21 through 6/25/21 at 4:05 P.M. showed:
- On 6/22/21 at 4:05 P.M., Resident #10 sat at a table in the dining room with a tub of crayons coloring in a coloring book and four other residents watched TV in the Unit dining room. No other activities observed.
During an interview on 6/22/21 at 1:03 P.M., CNA G said he/she works alone on the Dementia Unit most days. CNA G said he/she has to call out to the main floor to get assistance of another CNA to help with transfers of residents that require two staff assist. The facility has not had an activity director in a while, and there are no planned activities on the Unit. CNA G said he/she is not able to provide group activities for those residents that would participate as the other residents can't be left unattended. Some of the residents on the unit will color with crayons in the coloring books while watching TV in the dining room.
During an interview on 6/23/21 at 10:10 A.M., the Director of Nursing (DON) said the Activity Director had left the position back around November or December. Due to our low census, the company will not let us hire a new Activity Director at this time. The Business Office Manager (BOM) and the Social Services Director (SSD) has been helping and doing some activities since then. The SSD is on vacation this week.
Record review of the facility's Resident Activities, dated March 2012 showed:
- The Activities Services of each facility will plan, organize, and carry out a program of activities to meet individual resident needs. The program is designed to give residents entertainment, communication, exercise, relaxation and an opportunity to express their creative talent. Through the activities, residents can fulfill basic psychological, social and spiritual needs.
- The Activity Director plans and organizes a program of approved activities for residents on a group level and for individuals, to meet the needs of the residents. A calendar of events will be posted on the activity bulletin board to inform residents, visitors and staff of scheduled activities. All staff is responsible for assisting residents to activities of their choice.
- The calendar should include a wide variety of activities to meet all aspects of daily living.
- Activities should be planned for both large and small groups.
- Activities need to be addressed for all genders in the facility.
- Activities are scheduled in cooperation with resident choice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 restorative nursing services for two residents (Resident #1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide restorative nursing services for two residents (Resident #12 and #13) out of 15 sampled residents. The facility census was 39.
1. Record review of Resident #12's June 2021 POS showed:
- Diagnoses of generalized muscle weakness, difficulty walking, need for assistance with personal care and unsteadiness on feet
- No order for Restorative Nursing Program (RNP).
Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 3/25/21 showed:
- Extensive assist of one staff for bed mobility and transfers;
- Extensive assist one one staff for dressing, toilet use, and personal hygiene;
- Impairment on both lower extremities.
Record review of the resident's Therapy Discharge instructions, showed:
- On 5/17/21, discharge from Occupational Therapy (OT) services with recommendations for RNP to be established to enable the resident to maintain gains made in therapy;
- On 5/10/21, discharge from Physical Therapy (PT) services with recommendations for RNP to be established to enable the resident to maintain gains made in therapy.
Review of the medical record showed the resident not receiving restorative services.
2. Record review of Resident #13's June 2021 POS showed:
- Diagnoses of generalized muscle weakness, difficulty walking and repeated falls.;
- No order for RNP.
Record review of the resident's quarterly MDS, dated [DATE] showed:
- Limited assist of one staff for bed mobility and transfers;
- Extensive assist one one staff for dressing, toilet use, and personal hygiene;
- Impairment on lower extremities.
Record review of the resident's Therapy Discharge Instructions showed:
- On 12/16/20 OT- Therapy recommended an individualized RNP to enable resident to maintain gains made with skilled therapy;
- On 12/21/20 PT- Therapy recommended an individualized RNP to in order to maintain gains made with skilled therapy services.
Review of the medical record showed the resident not receiving restorative services.
During an interview on 6/23/21 at 9:48 A.M. the resident said he/she has limited range of motion (ROM) to her legs and tries to exercise by himself/herself.
During an interview on 6/24/21 at 4:00 P.M. the Director of Nursing (DON) said the facility did not have a restorative aide at this time and have not for some time. She said she had spoken with therapy and will start receiving the resident's therapy discharge instructions.
Record review of the facility's policy on Criteria for RNA Program, dated May 2006, showed;
- The RNA program is a means of providing restorative treatment to those residents identified as having a change in function that has stabilized and is no longer in need of skilled intervention or resident who exhibit a potential for decline.
- A resident may be referred to the RNA program following the stabilization of previous interventions and the need to established that these interventions can be maintained or slightly improved over a defined period of time after which a resident can be discharged to CNA level of care.
- Referrals to the RNA program may be made by nursing, PT, OT, ST and physicians, as well as through the MDS process, CNA and family/resident input.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate staffing for the locked dementia unit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate staffing for the locked dementia unit (a separate part of the building that is designated for residents who have Alzheimer's and other types of dementia and need special care) by staffing only one employee on every shift for 10 residents. The facility also failed to ensure adequate staffing to provide consistent resident care for activities of daily living (ADLs) which effected ten residents (Resident #4, #7, #12, #13, #26, #27, #28, #31, #39, and #189), a restorative nursing program which effected two residents (Residents #12 and #13), and activities which had the potential to effect all residents. The sample size was 15. The facility census was 39.
1. Observation of the Dementia Unit on 6/22/21 at 12:48 P.M. showed:
- Ten residents seated in the dining room for lunch;
- One staff member, Certified Nurse Assistant (CNA) G;
- CNA G sat and assisted Resident #4 with his/her meal;
- Resident #189 began to yell that he/she could not chew the meat;
- Another resident got up and walked out of dining room to go the the bathroom;
- CNA G got up from assisting the resident with eating to follow the other resident that was going to the bathroom;
- CNA G left the dining room to assist the resident to the bathroom;
- Nine residents left unattended in the dining room while eating;
- Resident #4 began to yell because CNA G got up and left him/her with food still on his/her plate;
- A resident that was across the table where Resident #4 sat, reached over and took his/her dessert cup and began to eat it;
- Resident #4 began to yell at the resident who took his/her dessert cup;
- One resident moved away from his/her table and began pulling on the trash bag that hung from the side of the dirty tray cart;
- Resident #189 continued to yell that he/she could not chew the meat on his/her plate;
- CNA G returned to the unattended dining room after assisting the resident to the bathroom.
Record review of Resident #189's medical record, showed:
- Resident admitted on [DATE];
- Comprehensive Nutrition Assessment, dated 6/9/21, showed current diet order of Level 5 Minced and Moist, oral problems edentulous (without teeth);
- Physician Order Sheet, dated 5/24/21 through 6/24/21, showed diet order for Level 5 Minced and Moist, started 6/4/21.
Observation of Resident # 189 on 6/22/21 at 1:03 P.M., showed;
- Resident served a whole baked pork chop, steamed squash, buttered noodles, slice of bread, and fruit jello for lunch;
- Resident held the whole pork chop up in the air with his/her bare hand, yelling I can't eat this meat, I don't have any teeth;
- Resident complained repeatedly while CNA G on duty continued to assist other residents in the dining room;
- Resident ate a few bites of the buttered noodles and the cup of fruit jello;
- Resident was not offered an alternative meal at that time.
During an interview on 6/22/21 at 1:10 P.M., CNA G said if a resident has trouble eating their food, she will notify the charge nurse or therapy department that the resident needs a speech evaluation and may need their diet order changed.
During an interview on 6/22/21 at 1:03 P.M., CNA G said he/she is scheduled to work alone on the Dementia Unit most days. CNA G said he/she has to call out to the main floor for assistance of another CNA to help with transferring of residents that require two staff assist. CNA G said he/she left the residents in the dining room because the resident who got up and left was a fall risk. CNA G said it is very difficult to keep up with all the residents and needs more help. CNA G said the facility does not have shower aides, so it is up to the CNAs to provide showers. CNA G said he/she is not able to give showers because he/she can't leave the other residents unattended. CNA G said he/she gives the residents on the Unit a quick bedside bath in place of a shower, that way she can still hear what is going on with the other residents on the hall. CNA G said the facility has not had an Activities Director in quite a while, so there are no activities scheduled. CNA G said he/she is not able to provide group activities for those residents that would participate, because he/she can not leave the other residents unattended.
During an interview on 6/22/21 at 4:05 P.M., CNA D said she is scheduled to work alone most of the time on the Dementia Unit during the evening shift. CNA D said he/she is not able to give residents showers since she is by him/herself. CNA D said he/she tries to give them a quick bed bath as needed, but has to be able to know what's going on with all the residents and not leave them unattended. CNA D said he/she does everything by herself at meal time, and has no help while feeding the residents on the Unit.
2. Record review of facility shower sheets showed:
- Resident #7 received two showers from 04/21 - 6/21/21;
- Resident #28 received one shower from 4/23/21 - 06/21;
- Resident #31 received four showers from 4/7/21 -6/17/21;
- Resident #35 received one shower from 4/21- 6/21/21;
3. Observations made throughout the survey dates 6/22/21 to 6/25/21 showed no formal or group activities being completed on any units throughout the facility. The posted activities calendar was blank.
Interviews with residents showed Residents #7, #26, #28 and #31 all agreed they would like to attend activities, but none are offered.
During an interview on 6/23/21 at 10:10 A.M., the Director of Nursing (DON) said the Activity Director had left the position back around November or December. Due to our low census, the company will not let us hire a new Activity Director at this time. The Business Office Manager (BOM) and the Social Services Director (SSD) has been helping and doing some activities since then. The SSD is on vacation this week.
4. Record review showed:
- Resident #12's Occupational Therapy (OT) discharge instructions, dated [DATE], and Physical Therapy (PT)discharge instructions, dated [DATE] recommended a Restorative Nursing Program (RNP);
- Resident #13's OT discharge instructions, dated [DATE] and PT discharge instructions, dated [DATE] recommended a RNP;
- Neither Resident #12 or #13 received restorative services.
During an interview on 6/24/21 at 4:00 P.M. the DON said the facility did not have a restorative aide at this time and have not for some time. She said she had spoken with therapy and will start receiving the resident's therapy discharge instructions.
During an interview on 6/25/21 at 11:10 A.M. the DON and Administrator said the facility had initiated a sign-on bonus and attempted other initiatives to obtain staff. She said when the census is low, they have to watch staffing closely. The DON and Administrator had nothing further to add regarding staffing issues on the main floor or the Dementia Unit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to conduct the required annual competency of Dementia Care (training for individuals with cognitive impairments), out of the two nurse aides s...
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Based on interview and record review, the facility failed to conduct the required annual competency of Dementia Care (training for individuals with cognitive impairments), out of the two nurse aides sampled. The facility census was 39.
Record review of the facility's in-service records showed:
- Certified Nursing Assistant (CNA) B had a hire date of 6/13/17;
- CNA B did not attend an annual competencies in-service on Dementia Care.
Record review of the facility's in-service records showed:
- CNA D had a hire date of 2/18/15;
- CNA D did not attend an annual competencies in-service on Dementia Care.
During an interview on 6/24/21 at 3:48 P.M., the Director of Nursing said they missed offering an in-service on Dementia Care for this past year, but will plan to include it annually in the future.
The facility did not provide a policy on nurse aide training requirements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders to provide a minced and moist...
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 follow physician orders to provide a minced and moist diet (food that is soft, moist, can be easily formed into a ball, can contain small lumps that can be broken up with the tongue rather than the teeth) for one resident (Resident #189) of 15 sampled residents. The facility census was 39.
1. Review of Resident #189's medical record, showed:
- Resident admitted on [DATE];
- Comprehensive Nutrition Assessment, dated 6/9/21, showed current diet order of Level 5 Minced and Moist, oral problems edentulous (without teeth);
- Physician Order Sheet, dated 5/24/21 through 6/24/21, showed diet order for Level 5 Minced and Moist, started 6/4/21.
Observation of Resident on 6/22/21 at 1:03 P.M., showed;
- Resident served a whole baked pork chop, steamed squash, buttered noodles, slice of bread, and fruit jello for lunch;
- Resident held the whole pork chop up in the air with his/her bare hand, yelling I can't eat this meat, I don't have any teeth;
- Resident complained repeatedly while Certified Nurse Aide (CNA) G on duty continued to assist other residents in the dining room;
- Resident ate a few bites of the buttered noodles and the cup of fruit jello;
- Resident was not offered an alternative meal at that time.
During an interview on 6/22/21 at 1:10 P.M., CNA G said if a resident has trouble eating their food, she will notify the charge nurse or therapy department that the resident needs a speech evaluation and may need their diet order changed.
During an interview on 6/25/21 at 9:30 A.M., the Dietary Manager said the kitchen is sent a diet order from the nursing department for the resident when they are admitted or the order has changed. The diet is written on a tray card for the resident, and the plate is prepared for the resident as it shows on the card. The card is placed on the tray at each meal so the nursing staff knows who to serve the tray to. She can not say if the nursing staff delivers each plate to the correct resident. Resident #189's tray card shows he/she is to get a Level 5 Minced and Moist diet.
During an interview on 6/25/21 at 11:20 A.M., the Director of Nursing said she would expect the residents be served the correct diet ordered at each meal, and alternative meals are available for the residents.
The facility did not provide a policy on resident diet orders.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 3 harm violation(s), $52,622 in fines, Payment denial on record. Review inspection reports carefully.
- • 52 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $52,622 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (8/100). Below average facility with significant concerns.
Bottom line: Trust Score of 8/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Hubble Creek's CMS Rating?
CMS assigns HUBBLE CREEK 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 Hubble Creek Staffed?
CMS rates HUBBLE CREEK's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 64%, which is 18 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Hubble Creek?
State health inspectors documented 52 deficiencies at HUBBLE CREEK during 2021 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 48 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 Hubble Creek?
HUBBLE CREEK is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 105 certified beds and approximately 45 residents (about 43% occupancy), it is a mid-sized facility located in JACKSON, Missouri.
How Does Hubble Creek Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, HUBBLE CREEK's overall rating (2 stars) is below the state average of 2.5, staff turnover (64%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Hubble Creek?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Hubble Creek Safe?
Based on CMS inspection data, HUBBLE CREEK 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 Hubble Creek Stick Around?
Staff turnover at HUBBLE CREEK is high. At 64%, the facility is 18 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 62%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Hubble Creek Ever Fined?
HUBBLE CREEK has been fined $52,622 across 3 penalty actions. This is above the Missouri average of $33,605. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Hubble Creek on Any Federal Watch List?
HUBBLE CREEK 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.