PARKVIEW HEALTHCARE
For profit - Limited Liability company
120 Beds
Independent
Data: November 2025
6 Immediate Jeopardy citations
Trust Grade
0/100
#438 of 479 in MO
Photo by Parkview Healthcare
Photo by Parkview Healthcare
Photo by Parkview Healthcare
1 / 5 photos
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Parkview Healthcare has received a Trust Grade of F, indicating significant concerns regarding the quality of care provided. With a state rank of #438 out of 479, they fall in the bottom half of facilities in Missouri, and at #36 of 38 in Jackson County, only two local options are worse. The facility is worsening, as the number of identified issues rose dramatically from 10 in 2024 to 31 in 2025. While the staffing situation is relatively stable with a turnover rate of 46%, which is better than the state average, the facility has faced $135,621 in fines, suggesting recurring compliance problems. Critical findings included the failure to maintain comfortable room temperatures for residents, inadequate emergency evacuation plans during heat emergencies, and poor infection control practices that led to potential COVID-19 spread among residents. Overall, while there are some staffing strengths, the numerous serious deficiencies raise significant red flags for families considering this facility.
- Trust Score
- F
- In Missouri
- #438/479
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $135,621 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Missouri. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 100 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 9%
Review needed
10 → 31 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 31 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 46%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Federal Fines: $135,621
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 100 deficiencies on record
6 life-threatening
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
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 transcribe physician orders correctly for an opioid pain medication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transcribe physician orders correctly for an opioid pain medication (controlled pain medication for moderate to severe pain) and failed to clarify the physician orders when the medication was not received by the pharmacy for one sampled resident (Resident #500) of out of 12 sampled residents. The facility census of 107 Residents.
1. Review of Resident #500's Face Sheet showed he/she admitted to the facility on [DATE] with a diagnosis of frost bite with necrosis (death of body tissue) to his/her left foot and non-pressure chronic wound (caused by prolonged pressure, arise from other factors like poor circulation, trauma, or infection) to his/her left foot.
Review of the resident's hospital discharge instruction and summary dated 3/1/25 at 1:50 P.M. showed:
-Had diagnosis to include frost bite to his/her left foot.
-Oxycodone (opioid-control substance pain reliever) 5 milligram (mg), give one tab by mouth every six hours as needed for severe pain (for 7-10 days) dated 3/2/25.
Review of the resident's physician's History and Physical Assessment Note dated 3/3/25 showed:
-He/she had reviewed the resident medication list from the hospital and listed on the physician order sheet.
-The resident was to receive Oxycodone-Acetaminophen 2.5 mg-325 mg, to give 2.5 mg tab by mouth every six hours as needed for severe pain dated 3/2/25.
Review of the resident's Physician Order Sheet (POS) dated March 2025 showed:
-Oxycodone-Acetaminophen 2.5 mg-325 mg, to give one-tab by mouth every six hours as needed for severe pain was ordered 3/2/25.
-Note: This was ordered from the pharmacy but not received. The order from the hospital was 5 mg and the facility POS order was for 2.5 mg.
Review of the resident's Medication Administration Record (MAR) dated 3/3/25 to 3/10/25 showed:
-Oxycodone-acetaminophen 2.5 mg-325 mg gives one-tab by mouth every six hours as needed for severe pain.
--This was not received by the pharmacy and not administered to the resident.
--Note: The resident had been treated by other non-opioid pan medications and his/her pain was documented as controlled.
During an interview on 3/17/25 at 4:20 P.M., the resident said:
-During the daytime his/her pain was under-controlled.
-He/she had more pain in his/her ankles and feet during nighttime when his/her feet were cold. The coldness in the air would cause his/her feet to hurt.
-He/she did not notify the nursing staff or asked for pain medication the during the night shift.
-He/she had been receiving other pain medication.
During an interview on 3/17/25 at 1:30 P.M. Registered Nurse (RN) A said:
-On 3/2/25 he/she contacted the hospital to have them send a written prescription for the resident's prescribed Oxycodone 5 mg, give one tab by mouth every six hours as needed for severe pain.
-The resident was getting alterative pain control medication.
-The resident pain medication order was as needed medication and the resident had to ask for those medication.
-The resident was to be seen by the physician on Monday and Friday.
-When a resident was admitted on Saturday, then he/she would be seen on Monday by the resident physician.
-Physician A would not write prescription for controlled pain medication until seen by him/her first.
-The resident had no complaints pain that was not controlled with alterative medication that was given.
During an interview on 3/17/25 at 3:30 P.M., Licensed Practical Nurse (LPN) A said:
-The facility cannot access the Pyxis (electronic pharmacy medication dispensing machine help ensure medications and supplies are available when and where they're needed) without pharmacy approval for each residents medication.
-The facility no longer has a tool box Emergency medication kit (E-Kit, that store extra common medication to include possible control substance medication) for those residents who were new admissions or a resident with new medication changes.
-The hospital did not send a written prescription for the oxycodone and the facility had reached out to the hospital with no response. The facility sent the medication list to pharmacy upon admission. The pharmacy required the physician to contact them to get the oxycodone filled.
-The resident had other non-opioid pain medications that were administered.
During an interview on 3/17/25 at 3:40 P.M., Registered Nurse (RN) A said:
-He/she would expect admitting nurse to follow-up with physician orders and pharmacy related to any medication not received as ordered including as needed opioid pain medication.
-He/she should have written a progress note that he/she had attempted to get the resident medication refilled on 3/3/25 and required a written script from the physician to be sent to pharmacy. The pharmacy was needing the physician medication number to be able fill the oxycodone medication.
-The resident did not voice concern with pain during the day shift.
-The resident's pain had been monitored and managed by other pain medications.
During an interview on 3/17/25 at 3:55 P.M., Director of Nursing (DON) said:
-He/she was not aware the resident was without as needed prescribed substance-controlled pain medication, which was not delivered to the facility.
-When a resident discharge from the hospital, would normally send a prescription or supply of medication with the resident, until the facility was able to obtain and send physician ordered for medication needed from pharmacy.
-He/she would expect nursing staff to document in progress notes the attempts to obtain medication and who had contacted to be able to get the medication was ordered upon admission.
-He/she had talked with the resident several times that week and never mention not having medication needed until 3/10/25.
-A new order was obtained for opioid pain medication on 3/10/25 when this was brought to his/her attention.
During an interview on 3/17/25 at 4:39 P.M. with Physician A said:
-He/she had approved the oxycodone, but the pharmacy needed an electronic script from him/her before could send the medication. Normally the facility sends the medication prescribed ordered to pharmacy and the pharmacy would have to notify the physician of any additional physician orders needed to include for opioid medication.
-He/she not made aware the resident did not receive the prescribed Oxycodone pain medication use as needed until 3/10/25 when he/she saw the resident.
-The resident had not voiced any complaints of uncontrolled pain while on site.
-He/she had observed the resident up walking with therapy staff that day.
-He/she would expect the facility nursing staff to contact him/her if not able to get pain medication.
-When reviewing the resident script submitted was noted as the wrong dosage to receive, the pharmacy does not have 2.5. mg tab for that pain medication.
-After review he/she noted the actual order was for 5 mg and to give ½ tab, which would be 2.5 mg to be given as needed for pain.
-That could have been the possible reason why the prescription did not go through.
Complaint # MO 00250736
Mar 2025
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #1) out of five...
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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 sampled resident (Resident #1) out of five sampled residents, was free from physical abuse. On [DATE], Resident #2 struck Resident #1 multiple times on the top of his/her head with a solid wood and metal cane, which resulted in Resident #1 sustaining a laceration to the left temple with four stitches, bruising to his/her left eye socket, defensive bruising on his/her left pinky, ring finger, and a laceration to his/her second knuckle to his/her right middle finger. Resident #1 was sent to the hospital for treatment and stated he/she was afraid of Resident #2. The facility census was 112 residents.
The Administrator was notified on [DATE] at 9:31 A.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification.
Review of the facility Resident Rights Policy, dated February 2023, showed:
-The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
-The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Review of the facility Abuse, Neglect and Exploitation Policy, dated [DATE], showed:
-It is policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.
-Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.
-The facility will develop and implement written polices and procedures that prohibit and prevent abuse, neglect, and exploitation of residents.
--The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident with needs and behaviors which might lead to conflict or neglect.
--Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of property more likely to occur.
-The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation, including by not limited to:
--Respond immediately.
--Examining alleged victim for any sign of injury.
--Increased supervision of the alleged victim and residents.
--Room or staffing changes, if necessary, to protect residents from the alleged perpetrator.
--Protection from retaliation.
--Providing emotional support and counseling to the resident during and after the investigation, as needed.
--Revision of the resident's care plan if the resident's medical, physical, mental, psychosocial needs or preferences change as a result of the incident of abuse.
1. Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses including paranoid schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations) and generalized anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).
Review of Resident #1's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated [DATE], showed the resident was moderately cognitively impaired.
Review of Resident #1's undated Care Plan showed:
-Potential for communication problem related to Spanish primary and English secondary.
--Resident will be able to make basic needs known on a daily basis.
---Ensure/provide safe environment.
Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including other psychoactive substance abuse (a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine), liver cell carcinoma (also known as hepatocellular carcinoma (HCC), is a type of cancer that occurs when malignant tumors grow in the liver), and adjustment disorder with anxiety (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior which can cause a lot of problems in getting along with others).
Review of Resident #2's Quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of Resident #2's undated Care Plan showed:
-Resident had a potential mood problem related to adjustment disorder with anxiety.
--Monitor, record and report to the doctor as needed risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used a weapons.
--Observe for signs and symptoms of mania (a state of abnormally elevated mood, energy, and activity) or hypomania (a state of elevated mood, increased energy, and activity that is less severe than mania), racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep, agitation or hyperactivity.
Observation of the facility video, dated [DATE], showed:
-Resident #1 observed at the juice cart then walking down the hall into the vending machine room.
-Resident #2 observed walking fast down the same hall holding a cane in both hands in a batting position.
-Resident #1 observed with his/her back towards Resident #2 as Resident #2 entered the vending machine room.
-Resident #2 went directly to Resident #1, raised the cane up with both hands and struck Resident #1 twice in the head.
-Resident #1 retreated several steps from Resident #2.
-Resident #2 advanced towards Resident #1 and struck Resident #1 in head with the cane again.
-Resident #1 stepped towards Resident #2 and grabbed the cane.
-Both residents continued to move and were no longer visible by the camera at that time.
-Staff were seen on camera enroute to the vending machine room.
-There was no audio to the footage.
Review of the police report, dated [DATE] at 9:34 A.M., showed:
-Incident type: Assault (Aggravated)
-On [DATE] at 9:34 A.M., law enforcement was dispatched to facility on a reported disturbance.
-Involved persons were Resident #1 and Resident #2.
-Witnesses were Resident #3 and Resident #4.
-Resident #1 reported being in the hallway when Resident #2 approached Resident #1 and began to argue with him/her.
-Resident #1 separated him/herself from Resident #2 and went to the break room.
-Resident #2 then followed Resident #1 into the break room and continued to argue with him/her.
-Resident #2 then hit Resident #1 in the face several times with a cane.
-Resident #1 took the cane from Resident #2 and began to hit Resident #2 with the cane.
-They were separated by staff.
-Resident #2 reported Resident #1's face got bloodied, because Resident #1 must have hit him/herself to make it look like Resident #2 assaulted him/her.
-Resident #4 reported Resident #1 was in the break room when Resident #2 entered and had some words with Resident #1. Resident #2 began to hit Resident #1 with the cane. Resident #1 took the cane from Resident #2 and began to hit Resident #2 with the cane. Resident #2 then left the break room and Resident #1 followed him/her, hitting him/her with the cane. He/She went to the break room and observed blood on the floor and trailed into the hallway.
-He/She observed a camera in the break room that would have captured the incident on video.
-The detective from the Assault Squad advised that city charges were appropriate.
-He/She was advised to contact the administrator at a later time to watch any video.
-He/She was unable to issue charges at that time due to not being able to determine a primary aggressor.
-The report was written prior to viewing or accessing any video recordings of the incident and may not reflect verbatim records of statements/interviews or evidence.
Review of the facility Suspected Abuse Investigation, dated [DATE], showed:
-Resident on resident incident occurred on [DATE] at 9:05 A.M.
-Resident #1 was in the vending machine room, Resident #2 entered the room carrying a wooden cane.
- The two began arguing, and the staff then witnessed Resident #1 swinging a broken cane at Resident #2.
-There was a laceration to Resident #1's head.
-The residents were separated and Resident #1 was placed on 1 on 1 supervision for safety.
-Police and physician were notified.
-Both residents were sent to the hospital for further evaluation.
-Law enforcement arrived on [DATE] at 9:35 A.M.
-Resident #1 was walking down the hall to the vending machine room and Resident #2 followed with cane in hand, not being used to walk.
-Resident #2 calmly asked where Resident #1 was and staff pointed down the hall.
-Upon entering the vending machine room where Resident #1 was already, Resident #2 hit Resident #1 in the head with the cane two times.
-Resident #1 held his/her head where he/she was hit.
-Resident #2 then hit Resident #1 in the head a third time and the cane broke in half.
-Resident #1 took the cane from Resident #2 and hit Resident #2 with the broken cane.
-Staff separated the residents and Assistant Director of Nursing (ADON, Director of Nursing (DON), Administrator and Law Enforcement notified.
-Resident #3 and #4 were witnesses.
-All involved parties were interviewed for statements.
-Resident #1 sustained laceration to the left side of head, left eye black, and right pinky finger bruised and jammed.
-Resident #2 had a small wound to the middle left side of forehead the size of a pea and a skin tear 1 centimeter (cm) in width in between the crease of thumb and pointer finger.
-Resident #1 received three stitches to the forehead.
-After hospital evaluations, both residents returned to facility and placed on 1 on 1 observation.
- After thorough investigation, it was determined that Resident #2 was the assailant, and Resident #1 was the victim.
-Police called and court date scheduled.
Review of Resident #1's Behavior Note, dated [DATE] at 8:11 P.M., showed:
-Licensed Practical Nurse (LPN) A was made aware that two residents (Resident #1 and #2) were involved in a physical altercation.
-LPN A was advised Resident #1 was in his/her room and was in need of assistance, while Resident #2 was on the other side being treated by that nurse.
-LPN A immediately went to Resident #1's room to treat and noted resident had a bloody towel on his/her head.
-Upon removing the towel advised resident the laceration appeared deep enough to receive stitches.
-Resident initially refused to go to the hospital.
-Management advised to call Emergency Medical Services (EMS) and to put resident on 1 on 1 observation at that time.
-Resident spoke to law enforcement before exiting the facility with EMS.
-The resident refused vital signs, was watching TV and was making several phone calls prior to leaving the facility making it difficult to assess and speak with the resident.
-The resident changed his/her shirt before leaving the facility with EMS.
-Hospital reported resident received three stitches on his/her head and was given discharge instructions.
Review of Resident #2's Behavior Note, dated [DATE] at 7:01 P.M., showed:
-LPN A was advised there was a physical altercation between Resident #1 and Resident #2 at approximately 9:28 A.M.
-LPN A was advised Resident #2 was being assessed and treated by the nurse on the other side of the facility.
-When LPN A went to assess Resident #2, he/she had a bandage on his/her forehead and was seated at the nurses station with staff present.
-At 9:31 A.M. LPN A began neuro assessments and notified management of the incident.
-At 9:46 A.M. law enforcement in facility to speak with the resident.
-Law enforcement advised there would be a report, provided a report number to the resident, and the resident verbalized an understanding.
-At 10:06 A.M. the resident began to complain of 10 out of 10 pain to his/her head.
-Resident had a pea size wound to forehead and approximately 1 cm wound to right hand between thumb and forefinger.
-As needed (PRN) pain medication given per resident's choice.
-Resident complained of dizziness and continued pain.
-Resident had previously refused to be assessed by EMS, at 10:12 A.M. requested to be sent to the hospital.
-Resident ambulated independently with no change or concern, and denied ongoing dizziness.
-Resident transported by EMS at 10:32 A.M. to the hospital.
-Resident returned to the facility at 2:22 P.M. with complaint of pain, but would not quantify pain.
-Resident stated he/she was poked in the back by Resident #1.
-LPN A observed a pea size mark to the mid-right back, resident denied any other injuries.
Review of Resident #1's hospital records, dated [DATE] at 2:40 P.M., showed:
-Resident was brought by EMS from nursing home with complaint of head injury.
-Resident was hit on the left side of his/her head with another resident's cane.
-Resident stated the nursing home made him/her come for evaluation.
-Denied headache, vision changes, weakness or numbness, neck pain or other injuries.
-Irregular laceration to left forehead.
-Dried blood on resident's face and t-shirt.
-Presented for head injury with cane, large open laceration.
-Met criteria for CT of head and neck.
-CT of head and neck showed no acute evidence of bleed or fracture.
-Laceration repaired with four sutures.
-Alert and oriented to person, place, time and situation.
-Social Services consult for assault.
-Protective service type, social services, adult/elderly abuse/neglect.
-Abuse/Neglect details: Resident was assaulted by another resident.
-Resident was anxious to return to the nursing home.
-Because resident was assaulted social worker completed adult protective services.
-Social worker assisted with transportation back to facility.
Review of Resident #1's Emergency Department discharge instructions, dated [DATE], showed:
-Reason for visit was head injury.
-CT (also known as a computerized axial tomography (CAT) scan, is a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body to diagnose and monitor various conditions, including fractures) of head and cervical spine (commonly known as the neck, is the upper portion of the spinal column that connects the skull to the thoracic spine) due to cane injury.
-He/She was seen for laceration (a cut that goes through all layer of the skin).
-Instructions for laceration care and follow up for stitches.
Review of Resident #2's Discharge Instructions dated [DATE] showed:
-Diagnosis from today's visit was assault and head injury.
-Rest and ice any areas of pain.
-Use your medications as previously prescribed.
-Tetanus administered.
-General head injury instructions given.
Review of the General Ordinance citation dated [DATE] showed:
-On [DATE] at 9:05 A.M. the Defendant, Resident #2, did unlawfully assault, in violation of Ordinance 50-169.
-Signed by the prosecutor.
During an interview on [DATE] at 11:20 A.M., the Administrator said:
-Both residents remain on 1 on 1 supervision.
-He/She was able to review the video of the assault.
-He/She was getting ready for a 30 day discharge notice for Resident #2 once placement is found, because Resident #2 was the aggressor.
-Resident #1 received three sutures while at the hospital for his/her injury.
-Resident #2 had superficial wounds to his/her hand and head.
-They reviewed the video and observed Resident #2 was the aggressor.
-The preliminary determination was an assault was made by Resident #2 and Resident #1 was protecting him/herself.
-There were no prior indicators between the two residents.
-Resident #2 was having a bad day as evidenced by the assault, although he/she was not exhibiting behaviors prior to attacking Resident #1.
-Resident #2 alleged he/she was the victim, even after observing the video.
During an interview on [DATE] at 1:18 P.M., Resident #1 said: (Communication was facilitated by Certified Medication Technician (CMT) A who was fluent in Spanish with consent from the resident.)
-He/She was getting some juice and Resident #2 came out yelling at him/her trying to fight.
-He/She did not engage with Resident #2 and just ignored Resident #2.
-He/She went to get a soda from the machine.
-He/She was bent over counting his/her credits when Resident #2 came to him/her yelling Today Motherfucker! repeatedly while hitting him/her with the cane.
-He/She raised his/her arms up in a protective stance to show how he/she was trying to protect his/her face and head while Resident #2 was hitting him/her with the cane.
-He/She said there was blood in his/her eyes and he/she could not see hardly at all.
-He/She took the cane from Resident #2 and attempted to defend him/herself.
-He/She swung the cane at Resident #2, making sure to not make contact with Resident #2's face.
-He/She was not sure if he/she struck Resident #2, but he/she was sure he/she struck the door frame breaking the cane in half.
-Law enforcement came, took pictures and filed a report.
-Law enforcement told him/her not to worry because Resident #2 would be arrested.
-He/She does not feel safe.
-He/She felt like his/her injury was serious, because he/she was hit was a cane. He/she was caught off guard with his/her back towards Resident #2 and bent down.
-He/She said when he/she was hit it hurt really bad.
-He/She was off balance and dizzy when he/she was hit with the cane.
-He/She felt he/she had to defend him/herself to get back to his/her room.
-He/She showed his wound to the left side of head (temple area), bruising to the left eye socket, bruising to the right pinky, right ring finger and small wound to the right middle finger.
-He/She complained of pain in all three fingers and was unable to bend the fingers without grimacing in pain.
-He/She complained of pain to the left side of head when it was touched or when chewing.
-He/She did not understand why this happened.
-He/She wanted Resident #2 to be punished and removed from the facility.
-He/She did not feel it was safe with Resident #2 in the facility and he/she was afraid of Resident #2.
During an interview on [DATE] at 3:06 P.M., the DON said:
-There was no arrest, law enforcement came to the facility on [DATE] to see Resident #2.
-Charges were filed for assault against Resident #2 and a court date was given to Resident #2.
-Both residents were on 1 on 1 observation indefinitely.
-Psychiatric appointments are being made for both residents.
During an interview on [DATE] at 3:15 P.M., Resident #2 said:
-Upon entering the room he/she said he/she was a little sore.
-They were in the vending machine room and Resident #2 hit him/her in the stomach.
-He/She went to his/her room and got the cane, went back to the vending machine room and hit Resident #2 in the head with the cane.
-He/She hopes to get moved and was not really happy in the facility.
-He/She then explained they were in the vending machine room and he/she had the cane with him/her.
-Resident #1 took the cane from him/her, hit him/her with the cane and broke it and stabbed him/her in the back.
-He/She then said he/she set the cane on the table in the vending machine room and Resident #1 grabbed the cane off the table and hit him/her with the cane.
-He/She grabbed the cane back and hit Resident #1 with the cane to defend him/herself.
-He/She alleged Resident #1 pushed and shoved him/her all of the time, but there are no reports, witnesses, or video evidence to support the allegation.
-He/She admitted to viewing the video footage of the incident and admitted he/she hit Resident #1 on purpose because he/she was gonna show him/her.
-He/She said he/she was getting out of here and that was what he/she wants.
-He/She said This is my ticket out of here and I'm going to take it.
-Although he/she hit Resident #1 intentionally, he/she did not mean to hurt Resident #1 as bad as he/she did.
Review of Resident #3's admission MDS, dated [DATE], showed the resident was cognitively intact.
During an interview on [DATE] at 4:40 P.M., Resident #3 said:
-He/She was in the vending machine room when Resident #2 came in swinging the cane.
-He/She immediately left the room to stay out of the way.
-He/She denied seeing exactly what happened after Resident #2 entered the room.
Review of Resident #4's admission MDS, dated [DATE], showed the resident was cognitively intact.
During an interview on [DATE] at 4:49 P.M., Resident #4 said:
-He/She was in the vending machine room watching TV at the time of the incident.
-He/She saw Resident #2 come into the vending machine room with a cane in his/her hands.
-Resident #2 swung the cane like a bat, striking Resident #1 in the head several times by the soda machine.
-Resident #1 took the cane away from Resident #2 and broke the cane on the door.
-He/She was not sure if Resident #1 hit Resident #2 with the cane.
During observation and interview on [DATE] at 5:18 P.M., the Administrator said:
-He/She said the incident does meet the criteria for abuse.
-He/She will ensure Resident #2 remains on 1 on 1 observation until discharged .
-He/She felt Resident #2 could be a threat again to possibly everyone in the building.
-A solid wood brown cane which was broken in half.
-There was a metal end with a large ball shape at the end of the handle, gold in color.
-There were traces of a red substance which appeared to be blood noted all over the cane.
During an interview on [DATE] at 3:51 P.M., LPN A said:
-He/She had went to the bathroom and upon returning he/she was informed there was a resident to resident altercation and someone was bleeding.
-He/She followed the blood trail and located Resident #1 in his/her room sitting on his/her bed with a bloody shirt, his/her phone in one hand, and holding a towel on his/her head with the other hand.
-CMT A was present to facilitate communication.
-He/She could tell right away the laceration needed stitches.
-Resident #1 was fearful, but spoke to law enforcement and then was transported to the hospital by EMS.
-He/She had seen Resident #2 pacing the hallways often, but never with a cane.
-He/She was confused as to who's cane Resident #2 used as it was the first time he/she saw the cane.
-The cane was heavy duty wood with a metal handle.
-Resident #1 comes out rarely, maybe one or two times for ice water, almost always in his/her room.
-He/She was shocked about the altercation, much less the use of a weapon.
During an interview on [DATE] at 7:53 A.M., CMT A said:
-He/She was at his/her medication cart when Resident #1 walked by talking about immigration.
-Resident #2 was speed walking following Resident #1 mumbling carrying a cane in both hands in front of him/her.
-Another resident came up to speak with him/her when he/she heard the commotion and called for help.
-He/She was on the opposite end of the hall.
-When he/she saw the residents, Resident #1 had the broken cane and was covered in blood.
-Resident #1 was walking towards him/her covered in blood with half of the cane.
-Resident #2 was following behind Resident #1 down the hall.
-He/She did not feel alarmed when Resident #2 went by with the cane as he/she thought Resident #2 was just doing his/her own thing.
During an interview on [DATE] at 11:10 A.M., the Physician said it was consensus the assault between Resident #1 and Resident #2 was abuse.
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
MO00250034, MO00250039, MO00250065
Feb 2025
29 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, record review and policy review, the facility failed to ensure residents were allowed to exerci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure residents were allowed to exercise their rights to make choices important to them, the right to privacy, and the rights to have care provided in manner that supported each resident's autonomy. The affected three residents (Resident (R) 31, R22 and R19) in the sample of 27 residents.
Findings include:
Review of the facility's policy titled, Dignity, revised February 2021, revealed, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings, of self-worth and self-esteem .
1. Review of R19's admission Record, provided by the facility, revealed an admission date of 03/09/23 with diagnoses that included diabetes mellitus, major depressions, and history of transient ischemia attacks.
Review of R19's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/23/24 located in the electronic medical record (EMR) under the MDS tab revealed R19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition.
During an interview on 02/17/25 at 2:39 PM, R19 was sitting on his bed with the door closed and while the resident was talking, the door was opened without any knocking. A housekeeping staff member came into the room and without any conversation, the unidentified staff member went through the room collecting trash. The staff member stepped out and without saying anything to the residents, the staff member placed bags in the trash receptacles. R19 was asked if that was the usual way staff entered the room when the door was closed. R19 stated there were some staff that knock. R19 was asked if that bothered him/her. R19 stated, Yes. What if I had been standing at my closet door when he/she entered. That could have hurt me.
During an observation on 02/17/25 at 3:15 PM, unidentified Housekeeping and dietary staff were standing at the end of the 200 halls. The staff were talking in elevated tones and were using curse words.
2. Review of R31's admission Record, provided by the facility, revealed an admission date of 10/15/24 with diagnoses that included lupus, end stage dialysis, and acquired bilateral amputations of lower extremities.
Review of R31's quarterly MDS with an ARD of 01/19/25 and located in the EMR under the MDS tab revealed R31 had a BIMS score of 15 out of 15, which indicated intact cognition.
During an interview on 02/18/25 at 8:50 AM, R31 was asked about being able to have privacy. R31 stated, No! They are so loud here that when I was talking to my (family member) on the phone a couple of days ago, he/she could hear them cursing. He/She asked who that was and I told him/her. He/She said that is so disrespectful. I said yeah, but that is how they are here.
During an interview on 02/21/25 at 9:49 AM, the Social Services Director (SSD) was asked if any of the issues related to staff not knocking before entering residents rooms and staff speaking in elevated tones and cursing had been brought to his/her attention. He/She stated he/she was not aware of the issues.
During an interview on 02/21/25 at 10:14 AM, the Staff Coordinator/ Human Resource (SC/HR) was asked what training the staff received. The SC/HR stated staff are trained on resident rights, including that all staff should knock on doors, and they should be respectful as they are in the residents' home.
3. Review of R22's Medical Diagnosis tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses that included left-side paralysis following a stroke.
Review of R22's admission MDS, with an ARD of 11/13/24 and located under the MDS tab of the EMR, revealed he/she scored 14 out of 15 on the BIMS, indicating intact cognition. It was recorded he/she did not exhibit mood or behavioral symptoms.
During an interview on 02/18/25 at 9:42 AM in R22's room, the SSD approached the room with R22's breakfast tray. R22 stated he/she did not want the meal tray in his/her room because it would sit in his/her room and not get picked up and he/she did not want to eat breakfast. The SSD stated he/she had to put the tray in his/her room, and R22 again said no. The SSD then placed the tray on R22's bedside table with him/her adamantly saying no. When the SSD exited the room, R22 stated, My ambition is to throw [the breakfast tray] in the hallway at him/her because I told him/her 'no' to begin with. They don't listen to us.
In an interview on 02/18/25 at 1:59 PM, the SSD stated he/she had to offer the resident a meal, which meant leaving the tray in his/her room in case he/she changed his/her mind. He/She stated he/she had to leave the tray in R22's room even though he/she stated several times he/she did not want it. The SSD stated he/she did not know if this was a facility policy, but it was just the way it was done. He/She stated he/she made sure to pick up his/her tray after the meal, so it was not left in his/her room, as that was the reason why he/she did not want it. The SSD stated the resident had the right to refuse his/her meal.
During an interview on 02/21/25 at 6:09 PM, the Director of Nursing (DON) stated staff were not expected to leave a tray in a resident's room if they have refused it. The DON stated staff were only required to offer a meal to each resident but were to respect residents' rights to refuse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to ensure residents were provided the correct ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to ensure residents were provided the correct form or provided the form that included the potential additional costs that the resident might have to pay if they chose to continue to receive services, Skilled Nursing Facility Advance Beneficiary Notice, form CMS-10055, for Medicare Part A Services when they were no longer covered or coverage was ending for three of three residents reviewed (Resident (R) 61, R110, and R114). This deficient practice had the potential to allow residents not to be provided the information about what services may not be covered by Medicare for residents to make an informed decision about receiving therapies.
Findings include:
Review of the facility policy titled, Advance Beneficiary Notices revised [DATE] revealed, Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. 5. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. A. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055.
1. Review of an undated document titled, SNF Beneficiary Notification Review for R61 indicated, .Medicare Part A Skilled Services Episode State date was: [DATE]. The last covered day of Part A Services was [DATE]. The form indicated, The facility-provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review of the document indicated, Was an SNF/ABN, Form (CMS-10055) provided to the resident? It was not marked, and there was no copy provided.
Review of R61's electronic medical record (EMR) revealed no documentation that communication took place between R61 and/or the representative to discuss potential additional costs that the resident might have to pay if they chose to continue to receive services.
2. Review of an undated document titled, SNF Beneficiary Notification Review for R110 indicated, .Medicare Part A Skilled Services Episode State date was: [DATE]. The last covered day of Part A Services was [DATE]. The form indicated, The facility-provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review of the document indicated, Was an SNF/ABN, Form (CMS-10055) provided to the resident? It was marked, yes. However, the copy that was provided was the wrong form. It was an ABM form that expired [DATE].
Review of R110's EMR revealed no documentation that communication took place between R110 and/or the representative to discuss potential additional costs that the resident might have to pay if they chose to continue to receive services.
3. Review of an undated document titled, SNF Beneficiary Notification Review for R114, indicated .Medicare Part A Skilled Services Episode State date was: [DATE]. The last covered day of Part A Services was [DATE]. The form indicated, The facility-provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review of the document indicated, Was an SNF/ABN, Form (CMS-10055) provided to the resident? It was not marked, and there was no copy provided.
Review of R114's EMR revealed no documentation that communication took place between R114 and/or the representative to discuss potential additional costs that the resident might have to pay if they chose to continue to receive services.
During an interview on [DATE] at 9:25 AM, the Social Service Director (SSD)was asked why the CMS-10055 was not provided for R61 and R114. The SSD stated he/she started at the end of [DATE] and did not know why there were no forms for the two residents. The SSD confirmed they should have been provided the forms and there should be copies. SSD was asked about the expired form that was given to R110. The SSD stated he/she was not aware there was another form and did not notice the form was expired.
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 record review, interview, and policy review, the facility failed to ensure the assessment accurately reflected weight a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure the assessment accurately reflected weight and significant weight loss for one (Resident (R) 52) of 12 residents reviewed for nutrition. This failure placed R52 at risk of additional unplanned weight loss or malnutrition.
Findings include:
Review of R52's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE] with diagnoses including: acute kidney failure, chronic kidney disease-stage four with dependence on renal dialysis, hyperkalemia (high potassium), hypomagnesemia (low magnesium), type 1 diabetes mellitus, anemia, and hypertension.
Review of R52's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/28/24 indicated his/her weight was 195 pounds (lbs) and he/she had not experienced any significant weight loss or gain.
Review of R52's weights found on the Weights and Vitals tab of the EMR revealed on 09/04/24, the resident weighed 193 lbs and on 10/01/24, the resident weighed 177.8 lbs, which is a 7.88% loss in one month.
Interview on 02/21/25 at 1:43 PM, the MDS Coordinator (MDSC) stated the Dietary Manager (DM) was responsible for completing the Nutrition and Weight section of the MDS. The MDSC stated the DM should have used the most recent weight on the MDS, which was 177.8 lbs, rather than 195 lbs. The MDSC stated if this was over 5% loss in one month, it would have met criteria for a significant weight loss and should have been coded on the MDS.
Interview on 02/21/25 at 2:33 PM, the DM stated he/she would typically use the most current weight when completing the assessment for weight loss and was unsure why R52's weight was recorded incorrectly. The DM stated he/she was not aware R52 had experienced a significant weight loss; however, he/she had been assessed by the Registered Dietician and interventions had been implemented.
Review of the facility's undated policy titled, Conducting an Accurate Resident Assessment revealed, The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identified resident strengths to maintain or improve medical status, functional abilities, and psychosocial status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure the Pre-admission Screening and Resident Rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) level I screening for mental disorder was completed for one (Resident (R) 36) of 27 residents in the sample. This failure had the potential for R36 to reside in the facility without a determination by the State mental health authority as appropriate for admission.
Findings include:
Review of R36's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE] with diagnoses including major depressive disorder, schizoaffective disorder, post-traumatic stress disorder (PTSD), and alcohol abuse and other psychoactive substance abuse with intoxication. He/She did not have a diagnosis of dementia.
Review of the Orders tab of the EMR revealed R36 had physician orders which originated on 08/26/24, for olanzapine (an antipsychotic medication), 5 milligrams (mg) at bedtime and 2.5 mg during the day for schizoaffective disorder.
Review of R36's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/02/24 and located under the MDS tab of the EMR revealed the Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R36 was cognitively intact. His/Her diagnoses included schizophrenia, depression, and PTSD.
Review of R36's EMR under the Miscellaneous tab revealed no evidence of a completed level I PASARR Screening.
During an interview on 02/20/25 at 11:16 AM, the Social Service Director (SSD) stated he/she was unable to locate a complete PASARR level I for R36 and was unsure whether it had been completed. The SSD stated the level I PASARR should have been completed prior to admission and available in the EMR for review.
Review of the facility's Resident Assessment - Coordination with PASARR Program policy, dated 2024, revealed:
1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening.
a. PASARR Level I - initial pre-screening that is completed prior to admission
i. Negative Level I Screen - permits admission to proceed and ends the PASARR process
unless a possible serious mental disorder or intellectual disability arises later.
ii. Positive Level I Screen - necessitates a PASARR Level II .
2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission.
3. A record of the pre-screening shall be maintained in the resident's medical record.
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 record review, interview, and policy review, the facility failed to develop and implement interventions for safety for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to develop and implement interventions for safety for two (Resident (R) 2 and R32) of two residents reviewed for substance use disorders.
Findings include:
1. Review of R2's Medical Diagnosis tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including anxiety, nicotine dependence, post-traumatic stress disorder, alcohol abuse, and bipolar disorder.
Review of R2's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/21/24 and located under the MDS tab of the EMR, revealed the Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 was cognitively intact.
Review of R2's Behavior note dated 10/16/24 and located in the Progress Notes tab of the EMR revealed, Resident tested positive for fentanyl [potent pain medication] during drug screen on 2 attempts this date.
Review of R2's Behavior note dated 10/17/24 and located in the Progress Notes tab of the EMR revealed, Several staff members including the RN [Registered Nurse] on duty report to LNHA [Administrator] that resident began to scream at, curse at, and threaten RN secondary to his/her medication dosage on controlled substances being reduced by physician secondary to his/her positive test and continued use of marijuana. Resident has been implicated by several residents including his/her roommate in providing drugs to other residents, caught with weed, and now tested positive for fentanyl. LNHA with SSD [Social Services Director] present for witness speak to resident about his/her behavior. Resident immediately begins to scream and curse at LNHA making threats to sue or call his/her (family member). LNHA explains you can involve an attorney, but continual violation of the facilities [sic] policies could lead to an immediate discharge. Resident continues to be argumentative. Resident has a history of substance use and distribution. Residents' [sic] previous facility indicated resident was removed for violation of drug/alcohol policy on their campus.
Review of R2's Care Plan, dated 12/30/24 and located under the Care Plan tab of the EMR, revealed it did not address R2's history of substance abuse, including interventions to prevent substance use in the facility as well as interventions for when substance use is suspected or identified
During an interview on 02/21/25 at 11:58 AM, the Director of Nursing (DON) stated he/she was unable to find an incident report, investigation, drug test result, or any other information regarding the incident.
2. Review of R32's Medical Diagnosis tab of the EMR revealed he was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, anxiety, alcohol dependence, and major depression.
Review of R32's quarterly MDS, with an ARD of 01/10/25 and located in the MDS tab of the EMR, revealed the BIMS score of 14 out of 15 which indicated R32 was cognitively intact.
Review of R32's Nurse's Note, dated 10/10/24 and located in the Notes tab of the EMR, revealed, Resident was observed with decreased LOC [level of consciousness] and lethargy. PCP [primary care physician] notified . drug test, and Narcan.
Review of R32's subsequent Nurse's Note dated 10/10/24 revealed, Did a drug test, was positive for Fentyl [sic], Morphine, and Suboxome [sic] . Called 911 they came and took him/her to the hospital.
Review of R32's hospital Discharge Summary, dated 10/12/24 and located under the Miscellaneous tab of the EMR, revealed, .Presenting today for concerns for opioid overdose. Per ED [emergency department] report, patient was found down in his/her nursing home and responded after receiving 4 mg [milligrams] of Narcan. Per the nursing home staff, UDS [urine drug screen] over there showed Fentanyl, which he/she doesn't use, and they are concerned he/she stole a Fentanyl patch.
Review of a physician's Post Hospital Note dated 10/14/24 and located in the Miscellaneous tab of the EMR revealed, Member admits to 'taking something with poison' when attempting to discuss altered mental status on 10/10. He/She does not specify further, however in-house drug testing kit tested on member's specimen via straight cath [catheter] did test positive for fentanyl and this information was relayed to hospital ED staff in report . Diagnostic Statement: Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications . Plan: Member has been discontinued from Norco due to testing positive for Fentanyl. Order in EMR for Narcan if clinically indicated. Contingency Plan: Nursing to monitor and notify provider if member experiences confusion, somnolence, LOC, or respiratory depression (RR [respiratory rate] less than 12 breaths/min). Narcan per protocol.
Review of R32's Care Plan dated 01/17/25 and located under the Care Plan tab of the EMR revealed it did not address R32's history of substance abuse, including interventions to prevent substance use in the facility as well as interventions for when substance use is suspected or identified.
During an interview on 02/21/25 at 11:58 AM, the DON stated he/she was unable to find an incident report, investigation, drug test result, or any other information regarding the incident.
During an interview on 02/21/25 at 2:53 PM, the SSD stated he/she would expect R2 and R32's Care Plan to address the resident's history of substance use disorder and drug use in the facility, including interventions to provide support, monitor for drug use, limit or monitor leave of absences, and complete drug screening as needed.
During a telephone interview on 02/21/25 at 4:59 PM, the Medical Director (who was also R2 and R32's physician) stated he/she thought R32 had obtained drugs from another resident. The Medical Director stated it would be important to include a history of substance use disorder in R2 and R32's Care Plan and develop interventions to increase monitoring, limit time away from the facility, encourage participation in cessation groups, and treat drug use/overdose.
Review of the facility's undated policy titled, Safety for Residents with Substance Use Disorder (SUD) revealed:
1. Residents with a history of SUD will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors.
2. When substance use is suspected (in the facility or upon return from an absence from the facility) which could lead to overdose, facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner.
3. Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge
planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and policy review, the facility failed to ensure three of three portable compre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and policy review, the facility failed to ensure three of three portable compressed oxygen cylinders were safely stored in a secure device. The deficient practice had the potential for severe physical harm if the pressurized cylinder was to be knocked over and explode. In addition, the facility failed to ensure respiratory equipment was kept in a clean and sanitary manner for one of three residents (Resident (R) R58) reviewed for oxygen usage in the sample of 27. Failure to provide clean oxygen tubing and oxygen filter increased the risk for respiratory problems related to contaminated equipment.
Findings include:
1. Review of the facility's policy titled, Oxygen Safety, revised May 2011 indicated, Store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. Never leave oxygen cylinders free-standing.
Review of the undated facility policy titled Oxygen Safety revealed, Policy: It is policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. h. When small-size (A, B, D, or E) cylinders in use, they shall -be attached to a cylinder stand or to medical equipment designed to receive and hold compressed gas cylinders.
Observation on 02/17/25 at 12:23 PM, revealed an Oxygen (O2) cylinder (Type E) in front of the East Nurses Station that was not attached to a cylinder stand or other medical equipment designed to hold a compressed gas cylinder. Oxygen tubing was attached to the O2 cylinder and lying on the floor. The compressed O2 cylinder was free standing upright in the hallway where residents ambulate and use their wheelchairs. Another O2 cylinder was observed free standing in the O2 storage room in front of the oxygen cylinder storage rack, not attached to a cylinder stand or other medical equipment designed to hold a compressed gas cylinder.
During an interview on 02/17/25 at 1:12 PM, Licensed Practical Nurse (LPN) 2 stated that he/she did not know why the cylinder was there by the nurses station or how long it had been there. LPN2 stated that O2 cylinders were kept in a bag or cart when not in the oxygen storage room. LPN2 stated that O2 cylinders were required to be stored in the O2 cylinder rack while in the oxygen cylinder storage room. An explosion could occur if an O2 cylinder gets knocked over. LPN2 stated that all staff and nurses were responsible for making sure tanks were secured and properly stored.
Observation on 02/17/25 at 12:23 PM, revealed an O2 cylinder (Type E) in front of the East Nurses Station that was not attached to a cylinder stand or other medical equipment designed to hold a compressed gas cylinder. Oxygen tubing was attached to the O2 cylinder and lying on the floor. The compressed O2 cylinder was free standing upright in the hallway where residents ambulate and use their wheelchairs. Another O2 cylinder was observed free standing in the Oxygen storage room in front of the oxygen cylinder storage rack, not attached to a cylinder stand or other medical equipment designed to hold a compressed gas cylinder.
During an interview on 02/17/25 at 1:12 PM, LPN2 stated that he/she did not know why the cylinder was there by the nurses station or how long it had been there. LPN2 stated that O2 cylinders were kept in a bag or cart when not in the oxygen storage room. LPN2 stated that O2 cylinders were required to be stored in the O2 cylinder rack while in the oxygen cylinder storage room. An explosion could occur if an O2 cylinder gets knocked over. LPN2 stated that all staff and nurses were responsible for making sure tanks were secured and properly stored.
During an observation on 02/20/25 at 1:40 PM, an unsecured E cylinder oxygen tank was next to the back of R31's wheelchair.
2. Review of R31's Physician Orders in the electronic medical record (EMR) located under the Orders tab dated 12/10/24 indicated Oxygen at 2 liter per minute (lpm) via nasal cannula use as needed for shortness of breath.
During an interview on 02/20/25 at 1:42 PM, Registered Nurse (RN) 1 observed the cylinder and stated it is not safe it should be in a stand. He/She was asked what could happen if the oxygen cylinder were to remain free standing. RN1 stated, It could fall over and explode.
During an interview on 02/21/25 at 6:33 PM, the Director of Nursing (DON) was asked about the oxygen being left free standing and not contained in a stand. The DON stated, Oxygen should always be placed in a stand. If the gauge breaks it becomes a missile.
3. Review of R58's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/24, revealed R58 was admitted to the facility on [DATE] with diagnoses that included the need for supplemental oxygen.
During an observation on 02/17/25 at 1:34PM, R58 was observed lying in bed with an oxygen concentrator on the right side of the bed near the handwashing sink in the room. The oxygen tubing was observed lying directly on the floor, and two different dates were observed on the tubing. The humidifier bottle was dated 01/25/25. The oxygen concentrator filter was coated on the outside with a heavy coating of gray dust.
During an observation on 02/18/25 at 12:25, the oxygen tubing had two different dates on it and remained rolled up but was directly on the floor, and the oxygen concentrator filter was gray colored.
During an interview on 02/19/25 at 10:34AM, LPN3 stated the oxygen tubing should not be lying directly on the floor due to the risk of contamination. After going to the resident's room, the oxygen tubing was discovered without any date and the humidifier bottle was observed to be dated 01/25/25. LPN 3 confirmed the oxygen concentrator filter needed to be cleaned and stated the tubing should be dated to show when it was changed last and did not know why it was not dated. LPN3 stated the equipment should be changed weekly, and the tubing needed to be stored in a bag.
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
Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed and signed by the physician for two of five sampled residents (Resident (R)19 and R60). This ...
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Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed and signed by the physician for two of five sampled residents (Resident (R)19 and R60). This deficient practice had the potential to allow residents to continue to receive medications with irregularities that the physician has not furnished a rational.
Findings include:
1. Review of R19's electronic medical record (EMR) revealed admission Record which indicated the admission date of 03/09/23 with diagnoses major depressions and anxiety.
Review of R19's quarterly Minimum Data Set (MDS)located in the EMR under the MDS tab with an assessment reference date (ARD) of 12/23/24 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognitive ability.
Review of R19's Physician Orders located in the EMR under the Orders tab revealed an order dated 07/08/23 for clonazepam oral tablet 1 milligram (mg) by mouth three times a day for anxiety; order dated 06/25/24 for sertraline tablet 25mg give one tablet by mouth one time a day for depression; and order dated 07/06/23 for doxepin oral capsule 25mg give two capsules by mouth at bedtime related to major depression disorder.
Review of pharmacy recommendations revealed the following:
On 07/24/24 the pharmacist recommended the clonazepam 1milligram (mg) three times a day and doxepin 50mg daily for the past year, be considered for a reduction to either agent if clinically appropriate. There was no response from the physician.
On 12/23/24 the pharmacist recommended sertraline 25mg daily since June. The pharmacist asked that it be considered to reduce the medication. There was no response from the physician.
2. Review of R60's EMR revealed admission Record indicated the admission date of 09/11/23 with diagnoses of anxiety and major depressive disorder.
Review of R60's quarterly MDS located in the EMR under the MDS tab with and ARD of 01/13/25 showed a BIMS score of 13 out of 15 indicating intact cognitive ability.
Review of R60's Physician Orders located in the EMR under Orders tab revealed an order dated 10/30/24 for Ativan oral tablet 0.5 mg one tablet by mouth two times a day for anxiety.
Review of pharmacy recommendations dated 3/21/24 and 09/23/24, the pharmacist recommended the Ativan 0.5mg two times a day for the last year, consider a trial reduction.
3. During an interview on 02/21/25 at 5:18 PM, the Medical Director was asked about the process of how the physician is aware of the pharmacist recommendations. The Medical Director stated the former Assistant Director of Nursing (ADON) use to get them and if they have to do with the psychotropic medications then I let the psychologist or the nurse practitioner address those medications. The expectation is that the recommendations be addressed no later than 30 days. They certainly should have been addressed before now.
During an interview on 02/21/25 at 6:10 PM, the Director of Nursing (DON) stated, the former ADON oversaw the pharmacy reviews and the recommendations. When he/she left we could not find what he/she had done with them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
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 that one of one resident (R)50) in the sample o...
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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 that one of one resident (R)50) in the sample of 27 revealed the resident's preference for a sandwich to be add to the lunch and dinner meals was not being honored. The failure to ensure that a resident's food preferences were honored could result in the resident loosing weight.
Findings include:
1. Review of R50's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE] with diagnoses including peripheral vascular disease, heart disease, and amputation of toes.
Review of R50's quarterly MDS with an ARD of 02/05/25 and located under the MDS tab of the EMR, revealed the BIMS score of 15 out of 15 which indicated intact cognition.
During an interview on 02/17/25 at 10:08 AM, R50 stated he/she was supposed to receive a sandwich with his/her meals, but he/she never received one. He/She explained his/her meal tickets documented he/she was to receive a sandwich with every meal because he/she did not feel like he/she got enough to eat with the regular meal.
During an observation on 02/17/25 at 1:18 PM, R50 received the regular meal of pork, mashed potatoes, and vegetables. There was no sandwich with the meal. The tray ticket documented, sandwich with meal. R50 stated he/she did not receive a sandwich but would have liked one.
During an observation on 02/19/25 2:06 PM, R50 was served his/her meal of a hot dog and chips. He/She did not receive a sandwich with the meal. R50 stated he/she did not receive a sandwich but would have liked one, as his/her meal was not enough. The tray ticket documented, Sandwich with meal.
During an interview on 02/21/25 at 7:02 PM, the Dietary Manager (DM) stated he/she had noticed R50 was not receiving sandwiches with lunch and dinner per his/her tray ticket. He/She stated the resident was to receive a sandwich.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and facility policy, the facility failed to implement infection prevention strategies to prevent cross-contamination during the medication pass for three of five resi...
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Based on observation, interviews, and facility policy, the facility failed to implement infection prevention strategies to prevent cross-contamination during the medication pass for three of five residents (Resident (R) 94, R316, and R18) observed during the medication pass out of a total sample of 27. This failure had the potential to spread infectious diseases to all residents. The facility census was 112 residents.
Findings include:
Observation on 2/19/25 at 9:13 AM. CMT6 did not sanitize the blood pressure cuff prior to taking R94's blood pressure.
Observation on 02/19/25 at 9:30 AM, CMT6 did not sanitize the blood pressure cuff prior to taking R316's blood pressure.
Observation on 02/19/25 at 9:41 AM, CMT6 did not sanitize the blood pressure cuff prior to taking R18's blood pressure.
During an observation on 02/19/25 at 9:13 AM to 10:05 AM, during medication administration, CMT6 failed to perform handwashing or hand hygiene prior to preparing medications for administration to R18.
During an interview on 02/19/25 at 2:27 PM, Registered Nurse (RN) 1 stated blood pressure cuffs are to be cleaned after each use, after each patient.
During an interview on 02/19/25 at 2:47 PM, CMT6 stated the blood pressure cuff is to be cleaned/sanitized after every 4-5 residents. CMT6 then stated he/she made an error and the blood pressure cuff should be after every resident.
During an interview on 02/20/25 1:26 PM, the Director of Nursing (DON) stated that vital signs equipment should be cleaned between every resident use, including blood pressure cuffs and glucometers and that hands should be sanitized between each resident contact or washed if soiled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure one (Resident (R) 32) of one resident review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure one (Resident (R) 32) of one resident review for antibiotic use in the sample of 27 had a duration of antibiotic therapy specified and antibiotic use did not continue without medical necessity. This failure placed R32 at risk of antibiotic resistance or unnecessary adverse effects of the medication.
Findings include:
Review of R32's Medical Diagnosis tab of the EMR revealed he was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease.
Review of R32's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/10/25 and located in the MDS tab of the EMR revealed he received antibiotics.
Review of R32's EMR under the Orders tab revealed a physician's order dated 01/10/24 to give one drop of Ofloxacin Ophthalmic Solution 0.3 % (antibiotic eye drops) in the left eye four times a day for cataract surgery. The order did not include a stop date.
Review of R32's Medication Administration Record (MAR) dated February 2025 and found under the Orders tab of the EMR, revealed the antibiotic eye drops had been administered four times daily from 02/01/25 to 02/18/25.
During an interview with Licensed Practical Nurse (LPN) 4 on 02/21/25 11:24 AM, he/she stated R32 received antibiotic eye drops four times a day since 01/10/24 and the order did not have a stop date.
Interview on 02/21/25 at 2:35 PM, the Director of Nursing (DON) stated R32 had cataract surgery and came back from the ophthalmologist with the order for antibiotic eye drops. The DON stated he/she needed to contact the resident's physician to make sure the eye drops should be continued.
During a telephone interview on 02/21/25 at 5:11 PM, the Medical Director (who was also R32's physician) stated the antibiotic eye drops order should have included a stop date, as typically the eye drops were used only for several weeks post cataract surgery.
During an interview on 02/21/25 at 5:28 PM, the Infection Preventionist (IP) stated he/she was not aware R32 had been receiving antibiotic eye drops since 01/10/24 and stated the order should have included a stop date. The IP stated if an antibiotic order did not include a stop date, the physician should be contacted for clarification. The IP stated all antibiotics should be included on the antibiotic tracking list and include stop dates. The IP stated he/she did not see R32's use of antibiotic eye drops beginning 01/10/24 on the facility's surveillance or antibiotic tracking list.
Review of the facility's policy titled, Antibiotic Stewardship, dated December 2016, revealed, The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents . If an antibiotic is indicated, prescriber will provide complete antibiotic order including the following
elements:
g. Duration of treatment:
(1) Start and stop date; or
(2) Number of days of therapy . and
i. Indications for use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the grievances voiced repeatedly by the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the grievances voiced repeatedly by the resident council were addressed and resolution presented to the council regarding food palatability, staff to resident interactions, pest control, and call light response. These failures had the potential to create feelings of dissatisfaction and helplessness among the eight residents who participated in Resident Council (R96, R2, R48, R88, R87, R109, R106, and R17) out of a census of 112 residents.
Findings include:
1. During the group meeting interview on 02/19/25 at 10:00 AM, there was seven participants, R96, R48, R88, R87, R109, R106, and R17.
a. Review of R48's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE]. Review of R48's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/10/24 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R48 was cognitively intact.
b. Review of R96's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R96's quarterly MDS with an ARD of 12/16/24 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R96 was cognitively intact.
c. Review of R88's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R88's admission MDS with an ARD of 12/06/24 and located under the MDS tab of the EMR, revealed a BIMS score of 10 out of 15 which indicated R88 had moderately impaired cognition.
d. Review of R87's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R87's quarterly MDS, with an ARD of 11/08/24 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R87 was cognitively intact.
e. Review of R109's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R109's admission MDS, with an ARD of 01/06/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R109 was cognitively intact.
f. Review of R106's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R106's annual MDS, with an ARD of 12/30/24 and located under the MDS tab of the EMR, revealed a BIMS score of 14 out of 15 which indicated R106 was cognitively intact.
g. Review of R17's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R17's quarterly MDS, with an ARD of 01/31/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R17 was cognitively intact.
During the meeting, all residents stated the food could be hot if you ate in the dining room, but if you chose to eat in your room the food is cold. R88, R106, R96, and R87 stated they preferred to eat in their rooms and received cold food most of the time.
All residents agreed there was a problem with staff being on their phones or talking in the halls while they were supposed to be caring for residents.
All residents stated the facility had a mouse problem and all had either seen a live mouse or a dead one.
2. Review of the facility's Resident Council Minutes from September 2024 through February 2025, provided on paper, revealed repeated concerns that were not addressed:
a. Food palatability
On 02/07/25, the minutes documented a complaint about cold food.
On 01/10/25, the minutes documented, Condiments not on trays, food still cold, staff refusing to warm up plates when asked . Burnt food, uncooked food, food presentation not good, late food arrival, need reeducating on cooking, and appeal of foods.
On 12/06/24, the minutes documented, Dining room aides/ Certified Nurse Aides (CNAs) on all shifts is [sic] not present in dining room in a timely manner to serve meals food is then cold . Issue with food temperature not resolved.
On 11/01/24, the minutes documented, Change the cook, meals are not up to par . Meals is [sic] always cold or lukewarm when being passed out both dining room and hallways.
On 10/04/24, the minutes documented, Residents stated that the food is served cold when they receive it from the hallway and in dining room.
b. Staff and Resident Interactions
On 01/10/25, the minutes documented, Nursing staff listening to music, talking on cell phones on all shifts . staff loud in hallways yelling to one another . Nursing staff with bad attitudes. The minutes also documented a resident reported a staff member was rude.
On 11/01/24, the minutes documented, Dietary staff are rude and disrespectful when inquiring or asking for something . Nursing staff do not give acknowledgement of [resident's] presence.
On 10/01/24, the minutes documented, . the CNA will tell him that she will be back meanwhile 3 hours have passed and no help. He/She feels ignore [sic] and confrontation from staff when needing help.
On 09/06/24, the minutes documented, Resident says [staff member] has a smart mouth when asking him/her a question about fixing things.
c. Pest Control
On 01/10/25, the minutes documented complaints of mouse sightings in three rooms
On 11/01/24, the minutes documented, Residents wants [sic] something to be done about the mice issue.
d. Call Lights
On 02/07/25, the minutes documented a complaint that it took too long for call lights to be answered on all shifts.
On 01/10/25, the minutes documented, Call light not being answered on time.
On 12/06/24, the minutes documented, Staff not answering residents in distress yelling for help. CNAs turn off call lights and don't address the resident. CNAs passes the bucket [sic] . Call light issues not resolved.
On 11/01/24, the minutes documented, Eastside station does not check on them nor acknowledge the call light- there was a call light issue on 10/31/24.
On 10/04/24, the minutes documented, Call light is not being answered in a timely manner.
3. Review of R96's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R96's quarterly MDS with an ARD of 12/16/24, revealed a BIMS score of 15 out of 15 which indicated R96 was cognitively intact.
During an interview on 02/17/25 at 3:37 PM, R96 stated he/she was the Resident Council President. He/She stated the Resident Council's suggestions and concerns were not always acted on and no resolution was presented to the council. He/She stated facility staff seemingly just blow us off.
Review of R2's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R2's quarterly MDS with an ARD of 12/21/24 and located under the MDS tab of the EMR, revealed a BIMS score of 14 out of 15 which indicated R2 was cognitively intact.
During an interview on 02/17/25 at 9:35 AM, R2 stated that when he/she attended Resident Council meetings before, grievances were voiced to administration, however, the group never received any follow-up. He/She stated the staff would tell him/her they were working on it, but there would never be any resolution or explanation of the final result.
4. During an interview on 02/21/25 at 11:58 AM, the Director of Nursing (DON) stated there were no grievance forms or Resident Council forms addressing food palatability, staff to resident interaction, pest control, or call light concerns with any resolution.
In a subsequent interview on 02/21/25 at 12:48 PM, the DON stated the facility had not yet taken any actions to address residents' concerns regarding food palatability, residents' concerns regarding staff to resident interactions, pest control (other than the routine pest control visits), or call lights. The DON added that the recommendations from the pest control visits had not yet been implemented, and the facility had conducted audits to ensure call lights were functioning, but no actions had been taken to address residents' concerns about call light wait times.
5. Review of the facility policy titled, Resident Council, dated February 2021, revealed, The purpose of the resident council is to provide a forum for:
a. residents, families, and resident representatives to have input in the operation of the facility;
b. discussion of concerns and suggestions for improvement;
c. consensus building and communication between residents and facility staff; and
d. disseminating information and gathering feedback from interested residents .
A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern.
Review of the facility policy titled, Grievances/Complaints, Recording and Investigating, dated April 2017, revealed, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from physical or verbal abuse by another resident for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse.
Findings include:
1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety.
Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52 was cognitively intact. He did not exhibit mood or behavioral symptoms.
Review of R52's Behavior note dated 06/25/24 and located under the Progress Notes tab of the EMR, revealed, [Social Service Director] was notified of altercation between a resident and his/her roommate, both resident and roommate was separated and redirected. Res [resident] was educated on the altercation and to follow the policies of the facility .
During an interview on 02/20/25 at 12:22 PM, R52 stated he/she remembered being hit by R26, who was his/her former roommate. He/She stated he/she was not afraid of R26 and had no further issues with him/her. He/She stated he/she remembered the police were called about the incident.
Review of the Medical Diagnoses tab of the EMR revealed R26 was admitted on [DATE] with a diagnosis of vascular dementia.
Review of R26's quarterly MDS with an ARD of 01/22/25 and located under the MDS tab in the EMR revealed BIMS score of 10 out of 15 which indicated that R26's cognition was moderately impaired. He/She did not exhibit mood or behavioral symptoms.
Review of R26's Care Plan, dated 12/31/23, revealed, [R26] is able to be physically aggressive [sic] to staff and other residents r/t dementia, history of harm to others (professional boxer), poor impulse control. The approaches included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; . Assess and address for contributing sensory deficits; . Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.; . Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; . Give the resident as many choices as possible about care and activities; . Monitor as needed. Document observed behavior and attempted interventions in behavior log; . Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of resident posing danger to self and others; . Psychiatric/Psychogeriatric consult as indicated; . [and] When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later.
Review of R26's Nurses Note, dated 06/25/24 and located under the Progress Notes tab of the EMR, revealed, Resident was in a physical altercation with his/her roommate. Stated roommate punched him/her in the back of the head so he/she went to his/her bed and started punching him/her. Cops called, doctor and administration notified, no injuries noted.
In an interview on 02/20/25 at 12:43 PM, R26 stated he/she did not have any fights with anyone in the facility and stated he/she felt safe in the facility.
Review of the facility's Incident Report for Physical Aggression Initiated for R26 dated 06/25/24 and provided on paper revealed, Nursing Description: Resident [R26] stated his/her roommate hit him/her in the back of the head and then went over to his/her roommate who was in his/her own bed and started punching him/her, roommate then came up to nurses station to report incident. Resident Description: He/She punched me in the head, so I went over and fought back .Immediate Action Taken: Residents separated, cops called, education given, administration notified, doctor notified. The incident was not witnessed.
Interview on 02/20/25 at 2:48 PM, the Administrator stated resident-to-resident altercations were abusive when there was willful action or an intent to harm someone. The Administrator stated he/she did consider the altercation to be physical abuse.
2. During an interview on 02/18/25 at 8:50 AM, R31 was asked if he/she had any issues or confrontations with any other resident. R31 stated, I had some problems with another resident, but we just stay away from each other.
Review of the Physical Aggression Initiated form dated 01/23/25 indicated the Incident Description revealed, This resident [R24] entered the dining room in his/her wheelchair and approached resident 2 [R31], being vocal towards resident 2 [R31]. Staff attempted to separate the two residents and this resident [R24] reached out and grabbed the left arm of resident 2 [R31]. This resident [R24] then struck the arm of the staff member as he/she was being wheeled away from resident 2 [R31]to come to the DON [Director of Nursing ] office.
Review of R24's EMR revealed, admission Record revealed the resident was admitted on [DATE] with diagnoses of mild cognitive impairment, anxiety disorder, and major depressive disorder.
Review of R24's quarterly MDS located in the EMR under the MDS tab with an ARD of 11/27/24 with a BIMS score of eight out of 15, indicating moderately impaired cognitive capabilities. The MDS documented, Physical behavioral symptoms directed toward others (e.g., hitting, kicking pushing, scratching, grabbing, abusing others sexually),occurred 1-3 days, Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), occurred 1-3 days.
Review of R31's EMR revealed admission Record revealed an admission date of 10/15/24 with diagnoses of lupus, end stage dialysis, and acquired bilateral amputations of lower extremities.
Review of R31's quarterly MDS located in the EMR under the MDS tab with an ARD of 01/19/25, showed a BIMS score of 15 out of 15 indicating intact cognitive ability.
During an interview on 02/20/25 at 2:49 PM, the Administrator was asked about the incident. The Administrator stated his/her investigation found no abuse because Neither resident felt threatened, scared, etc. It was determined that they had a disagreement.
During a follow up interview on 02/20/25 at 1:40 PM, R31 stated there had been another altercation with R24. R31 stated while in activities earlier, R24 came in and started wheeling around everybody. R31 stated, He/She started to come toward me, I told him/her to stay away. He/She started cussing at me and put his/her arms up like he/she was going to hit me. But the activities stopped him/her. R31 was asked if he/she was okay. He/She said, No, he/she keeps coming after me. I feel it's abuse.
During an interview on 02/20/25 at 1:48 PM, the Activities Assistant (AA) was asked what happened between R24 and R31 earlier. The AA stated R31 was in the activities this morning and then R24 came in and started over to R31, who told him/her to stay away. Then both residents' voices got louder, and then he/she stepped in between the residents as R24 was going towards R31. The AA stated the Social Service Director (SSD) heard loud voices and came in and took R24 out of the dining room.
During an interview on 02/20/25 at 2:05 PM, the SSD stated that the residents was arguing, and staff intervened.
During an interview on 02/21/25 a 10:05 AM, Maintenance Assistant (MA) was asked about the altercation between R24 and R31 on 01/23/25. The MA stated, I walked into the dining room because I could hear yelling. When I got in there, R24 was cussing at R31, and he/she was close to R31. The MA further stated he/she had gone up to them and [R24's name] shoved me, and he/she managed to grab on to [R31's name] and was about to hit him/her, but he/she hit me instead.
Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 revealed, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:
1. Protect residents from abuse .by anyone including .b. other residents .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and reporting of all alleged violations to the state survey agency (SSA) for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse.
Findings include:
1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he/she was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety.
Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52 was cognitively intact.
Review of R52's Behavior note, dated 06/25/24 and located under the Progress Notes tab of the EMR, revealed, [Social Service Director ] was notified of altercation between a resident and his/her roommate, both resident and roommate was separated and redirected
Review of the Medical Diagnoses tab of the EMR revealed R26 was admitted on [DATE] with a diagnosis of vascular dementia.
Review of R26's quarterly MDS with an ARD of 01/22/25 and located under the MDS tab in the EMR revealed a BIMS score of 10 out of 15 which indicated R26 had moderately impaired cognition.
Review of R26's Nurses Note, dated 06/25/24 and located under the Progress Notes tab of the EMR revealed, Resident was in a physical altercation with his/her roommate. Stated roommate punched him/her in the back of the head so he/she went to his/her bed and started punching him/her. Cops called, doctor and administration notified.
Review of the facility's Incident Report for Physical Aggression Initiated for R26 dated 06/25/24 and provided on paper revealed, Nursing Description: Resident [R26] stated /her roommate hit him/her in the back of the head and then went over to his/her roommate who was in his/her own bed and started punching him/her, roommate then came up to nurses station to report incident. Resident Description: He/She punched me in the head, so I went over and fought back . cops called .administration notified, doctor notified. There was no evidence the allegation was reported to SSA within two hours of occurrence.
Interview on 02/20/25 at 2:48 PM, the Administrator stated this incident represented resident-to-resident physical abuse. The Administrator stated he/she was unable to find any evidence the alleged violation was reported to the SSA as required. He/She stated it should have been reported to the SSA as an abuse occurrence.
2. During an interview on 02/18/25 at 8:50 AM, R31 was asked if he/she had any issues or confrontations with any other resident. R31 stated, I had some problems with another resident, but we just stay away from each other.
Review of the Physical Aggression Initiated form dated 01/23/25 indicated the Incident Description revealed, This resident [R24] entered the dining room in his/her wheelchair and approached resident 2 [R31], being vocal towards resident 2 [R31]. Staff attempted to separate the two residents and this resident [R24] reached out and grabbed the left arm of resident 2 [R31]. This resident [R24] then struck the arm of the staff member as he/she was being wheeled away from resident 2 [R31]to come to the DON office.
During an interview on 02/20/25 at 12:10 PM, the Director of Nursing (DON) stated the Administrator was the Abuse Coordinator, who reports abuse to the state.
Review of R24's electronic medical record (EMR) revealed, admission Record reveled the resident was admitted on [DATE] with diagnoses of mild cognitive impairment, anxiety disorder, and major depressive disorder.
Review of R24's quarterly MDS located in the EMR under the MDS tab with an ARD of 11/27/24 with a BIMS score of eight out of 15, indicating moderately impaired cognitive capabilities.
Review of R31's EMR revealed, admission Record revealed an admission date of 10/15/24 with diagnoses of lupus, end stage dialysis, and acquired bilateral amputations of lower extremities.
Review of R31's quarterly MDS located in the EMR under the MDS tab with an ARD of 01/19/25, showed a BIMS score of 15 out of 15 indicating intact cognitive ability.
During a follow up interview on 02/20/25 at 1:40 PM, R31 stated there had been another altercation with R24 while in activities earlier, R24 came in and started to come toward me. I told him/her to stay away. He/She started cussing at me and put his/her arms up like he/she was going to hit me. But the activities assistant (AA) stopped him/her. R31 stated, he/she keeps coming after me. I feel it's abuse.
During an interview on 02/20/25 at 1:48 PM, the AA stated R31 was in the activities this morning and then R24 came in and started over to R31, who told him/her to stay away. Then both residents' voices got louder. The AA said he/she stepped in between the residents as R24 was going towards R31.
During an interview on 02/20/25 at 2:49 PM, the Administrator stated his/her investigation found no abuse because Neither resident felt threatened, scared, etc. The Administrator confirmed the incident on 01/23/25 and the incident on 02/20/25 had not been called into the SSA.
Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, revealed, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives . Investigate and report any allegations within timeframes required by federal requirements.
Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated April 2021, revealed, The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:
a. The state licensing/certification agency responsible for surveying/licensing the facility .
3 Immediately is defined as:
a. within two hours of an allegation involving abuse or result in serious bodily injury; or
g. [sic] within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to ensure allegations of resident-to-resident abuse w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to ensure allegations of resident-to-resident abuse were investigated for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse.
Findings include:
1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety.
Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52's cognition was intact.
Review of the Medical Diagnoses tab of the EMR revealed R26 was admitted on [DATE] with a diagnosis of vascular dementia.
Review of R26's quarterly MDS with an ARD of 01/22/25 and located under the MDS tab in the EMR, revealed the BIMS score of 10 out of 15 which indicated R26 had moderately impaired cognition.
Review of the facility's Incident Report for Physical Aggression Initiated for R26 dated 06/25/24 and provided on paper, revealed, Nursing Description: Resident [R26] stated his/her roommate hit him/her in the back of the head and then went over to his/her roommate who was in his/her own bed and started punching him/her, roommate then came up to nurses station to report incident. Resident Description: He/She punched me in the head so I went over and fought back. There was no statement from R52 included, nor was there any evidence an investigation had been completed.
Interview on 02/20/25 at 2:48 PM, the Administrator stated this incident represented resident-to-resident physical abuse. The Administrator stated that he/she was unable to find any evidence of an investigation, including a statement from R52 or interviews with other residents and staff. He/She stated it should have been investigated thoroughly.
2. Review of the Physical Aggression Initiated form dated 01/23/25 indicated the Incident Description revealed, This resident [R24] entered the dining room in his/her wheelchair and approached resident 2 [R31], being vocal towards resident 2 [R31]. Staff attempted to separate the two residents and this resident [R24] reached out and grabbed the left arm of resident 2 [R31]. This resident [R24] then struck the arm of the staff member as he/she was being wheeled away from resident 2 [R31]to come to the DON office. The investigation included the form, progress notes, and R24's admission record.
During an interview on 02/20/25 at 12:10 PM, the Director of Nursing (DON)was asked if this was a complete investigation. The DON stated, yes. The DON was asked about witness statements, the root cause of the investigation and the result. The DON stated he/she would check with the Administrator and see if he/she had more.
The DON brought in three undated forms titled, Resident Interviews for Abuse, Neglect, and Exploitation filled out by random residents. The progress notes and the admission records were all printed out on 02/20/25, the same day that the investigation was requested. There was a typed page with the date of 01/24/25 with a recap of the incident and what followed such as care plan update, and a follow up visit from psychiatric dated 01/28/25.
Review of R24's electronic medical record (EMR) revealed, admission Record dated 02/20/25, provide by the facility, reveled the resident was admitted on [DATE] with diagnoses of mild cognitive impairment, anxiety disorder, and major depressive disorder.
Review of R24's quarterly MDS located in the EMR under the MDS tab with an ARD of 11/27/24 showed a BIMS score of eight out of 15, indicating moderately impaired cognitive capabilities.
Review of R31's EMR admission Record revealed an admission date of 10/15/24 with diagnoses of lupus, end stage dialysis, and acquired bilateral amputations of lower extremities.
Review of R31's quarterly MDS assessment located in the EMR under the MDS tab with an ARD of 01/19/25 showed a BIMS score of 15 out of 15 indicating intact cognitive ability.
During a follow up interview on 02/20/25 at 1:40 PM, R31 stated there had been another altercation with R24. R31 stated while in activities earlier, R24 came in and started wheeling around everybody. R31 stated, He/She started to come toward me, I told him/her to stay away. He/She started cussing at me and put his/her arms up like he/she was going to hit me.
During an interview on 02/20/25 at 2:49 PM, the Administrator was asked about the incident and stated his/her investigation found no abuse because Neither resident felt threatened, scared, etc. It was determined that they had a disagreement. The Administrator stated that if it were abuse it would have been investigated.
Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, revealed, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives . Investigate and report any allegations within timeframes required by federal requirements.
Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated April 2021, revealed, The individual conducting the investigation as a minimum:
a. reviews the documentation and evidence .
m. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident;
n. observes the alleged victim, including his or her interactions with staff and other residents;
o. interviews the person(s) reporting the incident;
p. interviews any witnesses to the incident;
q. interviews the resident (as medically appropriate) or the resident's representative;
r. interviews the resident's attending physician as needed to determine the resident's condition;
s. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;
t. interviews the resident's roommate, family members, and visitors;
u. interviews other residents to whom the accused employee provides care or services;
v. reviews all events leading up to the alleged incident; and
w. documents the investigation completely and thoroughly .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the electronic medication administration rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the electronic medication administration record (MAR) matched the Controlled Drug Administration Record Tablet for three residents (Resident (R)65, R97, and R86) out of a total sample of 27 residents. The deficient practice increased the risk of staff administering narcotic medication that had already been administered to residents which increased the risk of adverse effects.
Findings include:
1. Review of R65's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE], with diagnosis of chronic pain syndrome.
During an interview on 02/17/25 at 10:18 AM, R65 stated that his/her narcotic medications ran out consistently included: oxycodone (a narcotic pain medication) and buprenorphine (a narcotic pain medication).
Review of R65's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 11/22/24 for Oxycodone 10 milligrams (mg) to be administered every 8 hours as needed for moderate to severe pain. On 02/11/25, the order for oxycodone was revised to be administered for three days and a new order was written for Oxycodone 5 mg to be administered every 8 hours as need for pain.
Review of R65's Controlled Drug Administration Record Tablet provided by the facility dated 01/26/2025 and the MAR dated February 2025, located under the Orders tab of the EMR for Oxycodone 10mg revealed:
On 02/03/25 two of two doses administered were not documented on the MAR.
On 02/04/25 one of three doses administered was not documented on the MAR.
On 02/05/25 one of two doses administered was not documented on the MAR.
On 02/06/25 two of four doses administered were not documented on the MAR.
On 02/07/25 one of two doses administered was not documented on the MAR.
On 02/08/25 one of three doses administered was not documented on the MAR.
On 02/10/25 one of three doses administered was not documented on the MAR.
On 02/11/25 three of three doses administered were not documented on the MAR.
On 02/12/25 one of two doses administered was not documented on the MAR.
On 02/13/25 to 02/17/25 medication was out of stock
On 02/19/25 one of two doses administered was not documented on the MAR.
Review of R65's Controlled Drug Administration Record Tablet provided by the facility dated 02/17/25 and the Medication Administration Record, dated February 2025, located under the Orders tab of the EMR for Oxycodone 5 mg revealed:
On 02/19/25 one of two doses administered was not documented on the MAR.
Review of R65's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 02/11/25, the order for buprenorphine was revised to be administered for three days and a new order was written for Buprenorphine 8 mg sublingual tablet to be administered every 8 hours as need for pain.
Review of R65's Controlled Drug Administration Record Tablet sheets provided by the facility dated 01/26/25, 02/01/25, and 02/10/25, and the MAR dated February 2025 located under the Orders tab of the EMR for buprenorphine 2mg tablets revealed:
On 02/03/25 two of three doses administered were not documented on the MAR.
On 02/04/25 one of one dose administered was not documented on the MAR.
On 02/05/25 one of three doses administered was not documented on the MAR.
On 02/06/25 three of three doses administered were not documented on the MAR.
On 02/08/25 one of three doses administered was not documented on the MAR.
On 02/09/25 one of three doses administered was not documented on the MAR.
On 02/11/25 one of two doses administered was not documented on the MAR.
On 02/12/25 three of three doses administered were not documented on the MAR.
On 02/13/25 one of two doses administered was not documented on the MAR.
On 02/14/25 two of three doses administered were not documented on the MAR.
On 02/15/25 three of three doses administered were not documented on the MAR.
On 02/16/25 four of four doses administered were not documented on the MAR.
On 02/17/25 one of two doses administered was not documented on the MAR.
Review of R65's Controlled Drug Administration Record Tablet sheets provided by the facility dated 02/17/25 and the MAR dated February 2025 located under the Orders tab of the EMR for buprenorphine 8mg tablets revealed:
On 02/18/25 one of two doses administered was not documented on the MAR.
On 02/19/25 two of two doses administered were not documented on the MAR.
2. Review of R97's admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE] with diagnosis of chronic pain.
Review of R97's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 12/12/24 for Oxycodone 5 mg tablets to be administered every 4 hours as needed pain.
Review of R97's Controlled Drug Administration Record Tablet sheets provided by the facility dated 12/30/2024 and 02/08/25 and the MAR dated February 2025 located under the Orders tab of the EMR for Oxycodone 5mg revealed:
On 02/03/25 one of one dose administered was not documented on the MAR.
On 02/04/25 two of two doses administered were not documented on the MAR.
On 02/11/25 one of one dose administered was not documented on the MAR.
On 02/15/25 one of two doses administered was not documented on the MAR.
On 02/16/25 three of three doses administered were not documented on the MAR.
On 02/17/25 one of two doses administered was not documented on the MAR.
On 02/19/25 one of two doses administered was not documented on the MAR.
3. Review of R86's admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE], with diagnoses which included abdominal pain and neuropathy.
Review of R86's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 12/01/23 for Oxycodone 5 mg tablets to be administered every 6 hours as needed for moderate to severe pain.
Review of R86's Controlled Drug Administration Record Tablet sheets provided by the facility dated 01/24/25 and 02/07/25 and the MAR dated February 2025 located under the Orders tab of the EMR for Oxycodone 5mg revealed:
On 02/03/25 one of two doses administered was not documented on the MAR.
On 02/04/25 one of two doses administered was not documented on the MAR.
On 02/05/25 one of two doses administered was not documented on the MAR.
On 02/06/25 one of three doses administered was not documented on the MAR.
On 02/09/25 one of two doses administered was not documented on the MAR.
On 02/10/25 two of three doses administered were not documented on the MAR.
On 02/11/25 one of two doses administered was not documented on the MAR.
On 02/15/25 one of two doses administered was not documented on the MAR.
On 02/16/25 four of four doses administered were not documented on the MAR.
On 02/18/25 one of three doses administered was not documented on the MAR.
4. During an interview on 02/20/25 at 10:03 AM, Licensed Practical Nurse (LPN) 3 stated, we are required to document narcotics at the time of removal on the Controlled Substances Administration Record sheet and on the MAR in the computer. If we get busy, we might not sign them out on the computer. They want us to sign narcotics out both on the paper narcotics log and on the computer.
During an interview on 02/20/25 at 10:09 AM, Registered Nurse (RN)1 stated, to administer narcotic medications, we document on the paper narcotics log when removed and document in computer. The paper narcotic log is considered an administration record. The only time I would not document in the computer would be if the internet was down.
During an interview on 02/20/25 at 1:38 PM, the Director of Nursing (DON) stated, As soon as the medication is popped out, the medication is documented as removed from count on the Controlled Substances Administration Record sheet. Then, when the medication is administered, it is documented in the EMR on the MAR. The controlled substance record can be considered an administration record. The EMR is the required administration record. There should not be any instances where a controlled medication would not be documented in the EMR if documented on the Controlled substance record. I expect all medications to be documented on the EMR when administered.
Review of the facility's policy titled, Controlled Substances revised April 2019 indicated, Controlled substances are reconciled upon. administration. Upon administration: The nurse administering the medication is responsible for recording: 1) name of the resident receiving the medication; 2) name, strength, and dose of the medication; 3) time of administration; 4) method of administration; 5) quantity of the medication remaining; and 6) signature of nurse administering medication.
Review of the facility's policy titled, Administering Medications revised April 2019 indicated, As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; . e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interviews, and policy review, the facility failed to properly label insulin pens with resident name and opened date and discard expired insulin pens, keep food, personal items a...
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Based on observation, interviews, and policy review, the facility failed to properly label insulin pens with resident name and opened date and discard expired insulin pens, keep food, personal items and makeup separate from medications for two of six medication carts. The deficient practice could result in altered effectiveness of the medication, worsening of resident's symptoms,
Findings include:
1. Observation on 02/19/25 at 1:27 PM of the nurse's medication cart with Licensed Practical Nurse (LPN)3 on the 100 (East) hall revealed:
There were two Humalog insulin pens not labeled with the resident's name.
There were five Lantus insulin pens open and not dated.
There was one Levemir insulin pen that had an open date of 12/08/24.
There was one Lantus vial that had an open date of 12/10/24. LPN3 at the time of the observation the insulin was expired and is to be discarded within 28 days after the date opened.
A container of applesauce was found stored in the drawer with nebulizer medications.
There was lipstick and makeup found in the top drawer without a name. LPN3 stated at the time of the observation, that the makeup belonged to a resident but was unsure to whom.
Interview on 02/19/25 at 1:27PM, LPN3 stated the pens were opened/used.
2. Observation on 02/19/25 at 2:27 PM of the nurse's medication cart with Registered Nurse (RN)1 on the 200 (West) hall revealed:
There were three insulin pens that were opened and not dated. RN1 stated one pen had a date marked on it 2/17. The date was not legible and there was not a label to indicate if the date was when it was opened or when it expired.
There was a bottle of liquid Gabapentin oral solution that was opened and not dated.
There was a purse and cell phone in a drawer on top of patient medications. RN1 stated at the time of the observation that the personal items belonged to her.
There were two containers of pudding in a drawer with patient medications.
There were two bottles of sterile water that expired on 04/12/24.
RN1 stated at the time of the observation that food was not to be stored with medications and that the liquids are required to be dated when opened.
During an interview on 02/20/25 at 1:28 PM, the Director of Nursing (DON) stated that more than one resident could not use insulin pens. It is expected to have a resident label on each pen with the date opened. Each insulin pen was expected to be dated immediately when opened. The DON stated he/she thought insulin pens and vials would expire 30 days from date opened but was not sure. The DON stated applesauce, and pudding should not be stored in the medication carts and that personal items should not be stored in medication carts.
Review of the facility's undated policy titled, Storage of Medication Requiring Refrigeration, indicated The facility must provide safe and effective storage of all drugs and biologicals in a locked storage area under proper temperature controls. consistent with state and federal requirements and professional standards of practice. The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates (when applicable).Remove any expired medications from active stock and discard medication according to facility policy. Date label of any multi-use vial when the vial is first accessed (needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
Review of the facility policy titled, Administering Medications revised April 2019 indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review and record review, the facility failed to assure food was palatable and served ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review and record review, the facility failed to assure food was palatable and served at appetizing temperatures for 10 of 10 residents (R2, R22, R101, R63, R70, R40, R31, R65, R97 and R94) reviewed for food concerns out of a sample of 27. Additionally, review of Review of Resident Council Meeting Minutes revealed complaints related to food palatability from five of five months of minutes reviewed. Failure to serve palatable and appetizing foods placed all residents residing in the facility at risk for weight loss.
Findings include:
1. During meal service on 02/20/25, the [NAME] was observed testing temperatures of the foods on the tray line prior to starting tray service. A check of the log showed temperatures were recorded between 170 and 190 Degrees Fahrenheit (F). A test tray was requested from dietary and on 02/20/25 at 1:28 PM. The last tray cart left the kitchen for east hall residents who ate in their room and included the test tray. After the last trays were served to residents, a temperature and taste test of the regular diet was completed with the Dietary Manager (DM). The temperature of the chicken parmesan was 123 degrees F, the creamy rice was 121 degrees F, and the broccoli was 110 degrees F. The DM and surveyor tasted the food, which tasted cold. The DM stated at this time that the temperatures obtained affected palatability.
2. Review of R2's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE].
Review of R2's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/21/24 and located in the MDS tab of the EMR the Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 was cognitively intact.
During an interview on 02/17/25 at 9:35 AM, R2 stated the food was served cold. He/She stated facility residents were not allowed to use the microwave, and staff did not offer to heat up the food.
3. Review of R22's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE].
Review of R22's admission MDS with an ARD of 11/13/24 revealed the BIMS score of 14 out of 15 which indicated R22 was cognitively intact.
During an interview on 02/17/25 at 9:40 AM, R22 stated the meals were always cold. He/She stated he/she would like to heat up his/her food in a microwave, but he/she was not allowed.
4. Review of R70's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE].
Review of R70's quarterly MDS with an ARD of 11/16/24, revealed the BIMS score of 15 out of 15 which indicated R70 was cognitively intact.
During an interview on 02/17/25 at 9:53 AM, R70 stated the food did not taste good or look appetizing. During lunch in R70's room on 02/17/25 at 1:19 PM, R70 did not eat his/her meal, and stated he/she was not going to eat it, because it didn't look appetizing.
5. Review of R101's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE].
Review of R101's quarterly MDS with an ARD of 01/11/25 revealed the BIMS score of 15 out or 15 which indicated R101 was cognitively intact.
During an interview on 02/17/25 at 12:42 PM, R101 stated, The food is terrible.
6. Review of R63's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE].
Review of R63's admission MDS, with an ARD of 02/04/25 revealed the BIMS score of 15 out of 15 which indicated R63 was cognitively intact.
During an interview on 02/17/25 at 12:50 PM, R63 stated the food did not taste good or looked appetizing. He/She stated the food was not served hot.
7. Review of R40's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE].
Review of R40's significant change of status MDS with an ARD of 01/10/25 revealed the BIMS score of 15 out of 15 which indicated that R40 was cognitively intact.
During an interview on 02/17/25 at 3:51 PM, R40 stated he/she did not like the taste of the food.
8. Review of R31's EMR admission Record revealed an admission date of 10/15/24.
Review of R31's quarterly MDS located in the EMR under the MDS tab with an ARD of 01/19/25 showed a BIMS score of 15 out of 15 indicating intact cognitive ability.
During an interview on 02/18/25 at 8:57 AM, R31 was asked about the food. R31 stated the food tasted cold.
9 Review of R65's Clinical Census, located under the Census tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE].
During an interview on 02/17/25 at 10:18 AM, R65 stated, The food is terrible.
10. Review of R97's Clinical Census, located under the Census tab of the EMR, revealed the resident was admitted on [DATE].
During an interview on 02/17/25 at 12:13 PM, R97 stated, The food is cold. Lunch comes whenever; maybe by 1:30-2:00 PM.
11. Review of R94's Clinical Census, located under the Census tab of the EMR, revealed the resident was admitted on [DATE].
During an interview on 02/17/25 at 10:18 AM, R94 stated that the kitchen is a problem. Food tastes horrible. Food is not hot. The alternative is usually burritos or burgers.
12. The facility failed to ensure the grievances voiced repeatedly by the resident council were addressed and resolution presented to the council regarding food palatability. (Refer to F565)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected multiple residents
Based on interview, record review, and policy review, the facility failed to inform the 29 residents, R315, R77, R97, R104, R316, R72, R105, R61, R107, R68, R63, R24, R13, R108, R7, R106, R314, R67, R...
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Based on interview, record review, and policy review, the facility failed to inform the 29 residents, R315, R77, R97, R104, R316, R72, R105, R61, R107, R68, R63, R24, R13, R108, R7, R106, R314, R67, R62, R110, R22, R73, R109, R115, R119, R116, and R117, and/or their representatives who signed the binding arbitration agreement out of a census of 112 in writing they were not required to enter into a binding arbitration agreement as a condition of admission. This failure placed these 29 residents at risk of signing the agreement involuntarily.
Findings include:
Review of the facility's Arbitration Agreement Rider to the admission Contract, provided by the Administrator revealed, The parties agree that any and all disputes arising out of or in any way related to the contract or the Resident's stay at the facility . shall be decided by arbitration in accordance with this Rider. The arbitration proceeding and settlement shall remain confidential . The resident also understands that nothing in this Rider prevents him/her from communicating with federal, state, or local officials . The parties agree that the Operator shall pay the fees of the arbitrators: [sic] and Operator shall pay up to $5,000 of the Resident's attorney fees and costs . ; the Resident shall have the right to choose the location of the arbitration; and the Federal Arbitration Act would govern the proceedings . This Rider may be revoked within 30 days of this signed Arbitration Agreement Rider.
The agreement did not include a statement that neither the resident or his/her representative is required to sign the biding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility.
Review of an undated document titled, Signed & Uploaded Arbitration Agreements, provided by the Admissions Coordinator revealed 29 facility residents had entered into the binding arbitration agreement.
During an interview on 02/21/25 at 2:29 PM, the Admissions Coordinator stated the facility's arbitration agreement did not include the statement that neither the resident or his/her representative is required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. He/She stated residents were not required to sign the arbitration agreement on admission even though the form did not have a place to mark a declination.
Review of the undated facility policy titled, Binding Arbitration Agreements revealed This facility asks all residents to enter into an agreement for binding arbitration . The agreement must: . Explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0848
(Tag F0848)
Could have caused harm · This affected multiple residents
Based on interview, record review, and policy review, the facility failed to inform the 29 residents and/or their representatives (Resident (R)315, R77, R97, R104, R316, R72, R105, R61, R107, R68, R63...
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Based on interview, record review, and policy review, the facility failed to inform the 29 residents and/or their representatives (Resident (R)315, R77, R97, R104, R316, R72, R105, R61, R107, R68, R63, R24, R13, R108, R7, R106, R314, R67, R62, R110, R22, R73, R109, R115, R119, R116, and R117) who signed the binding arbitration agreement out of a census of 112 in writing of the right to selection of neutral arbitrator agreed upon by both parties. This failure placed these 29 residents at risk of misunderstanding the process for selection of an arbitrator.
Findings include:
Review of a copy of the facility's Arbitration Agreement Rider to the admission Contract, provided to the survey team by the Administrator, revealed, The parties agree that any and all disputes arising out of or in any way related to the contract or the Resident's stay at the facility . shall be decided by arbitration in accordance with this Rider. The arbitration proceeding and settlement shall remain confidential . The resident also understands that nothing in this Rider prevents him/her from communicating with federal, state, or local officials . The parties agree that the Operator shall pay the fees of the arbitrators: [sic] and Operator shall pay up to $5,000 of the Resident's attorney fees and costs . ; the Resident shall have the right to choose the location of the arbitration; and the Federal Arbitration Act would govern the proceedings . This Rider may be revoked within 30 days of this signed Arbitration Agreement Rider.
The agreement did not provide for the selection of a neutral arbitrator agreed upon by both parties.
Review of an undated document titled, Signed & Uploaded Arbitration Agreements, provided by the Admissions Coordinator, revealed 29 facility residents had entered into the binding arbitration agreement.
During an interview on 02/21/25 at 2:29 PM, the Admissions Coordinator stated the facility's arbitration agreement did not provide for selection of a neutral arbitrator agreed upon by both parties.
Review of the undated facility policy titled, Binding Arbitration Agreements revealed The agreement must: . Provide for the selection of a neutral arbitrator agreed upon by both parties.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure five of five residents (Resident (R) 85, R70...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure five of five residents (Resident (R) 85, R70, R107, R34, and R95) residents reviewed for immunizations out of a total sample of 27 were assessed for eligibility, educated on the risks and benefits, and offered pneumococcal vaccination. This failure placed all eligible residents who wished to receive the vaccine at risk for contracting pneumonia unnecessarily.
Findings include:
In an interview on 02/21/25 at 5:21 PM, the Infection Preventionist (IP) stated he/she had just taken over the position about a month ago, and the former Assistant Director of Nursing who no longer worked at the facility had been in charge of the infection prevention and immunization program prior. He/She stated immunizations were documented either on paper in binders he/she kept or in the electronic medical record (EMR). The IP stated he/she was working on getting immunizations caught up, and stated he/she was able to administer influenza and COVID-19 immunizations but had not yet gotten to the pneumococcal vaccines. He/She stated he/she planned to address this next by assessing all residents to determine who needed the vaccine.
1. Review of R85's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses of paraplegia and vascular disorder of the intestine.
Review of R85's EMR under the Immunizations tab revealed no documentation regarding offering or administering the pneumococcal vaccine.
During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in R85's records.
2. Review of R70's Medical Diagnosis tab of the EMR revealed he/he was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease and heart disease.
Review of R70's EMR under the Immunizations tab revealed no documentation regarding offering or administering the pneumococcal vaccine.
During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in R70's records.
3. Review of R107's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure.
Review of R107's EMR under the Immunizations tab revealed no documentation regarding offering, refusal, or administering the pneumococcal vaccine.
During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in R107's records.
4. Review of R34's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE] with a diagnosis of congestive heart failure.
Review of R34's EMR under the Immunizations tab revealed no documentation regarding offering, refusal, or administering the pneumococcal vaccine.
During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in R34's records.
5. Review of R95's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease.
Review of R95's EMR under the Immunizations tab revealed no documentation regarding offering, refusal, or administering the pneumococcal vaccine.
During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in R95's records.
Review of the facility's policy titled, Pneumococcal Vaccination, dated October 2019, revealed, All residents will be offered pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infections . Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission . Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine . Provision of such education shall be documented in the resident's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to maintain a safe and comfortable environment for six...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to maintain a safe and comfortable environment for six rooms (Resident (R) 70, R56, R94, and R65, room [ROOM NUMBER], and room [ROOM NUMBER]) of 32 rooms observed in Initial Pool.
Findings include:
1. During an interview on 02/21/25 at 7:08 PM, the Regional Maintenance Consultant (RMC) stated he/she had just been hired to start implementing the necessary corrective measures to ensure a safe, clean, and comfortable environment. The RMC stated he/she did notice issues with walls in disrepair, broken heating vents or light fixtures, and other maintenance issues. The RMC stated the Maintenance Director had been at the facility for about a year and a half and he/she did not know why the issues had not yet been addressed and stated the Maintenance Director needed training on time management and prioritization. The RMC stated the facility had just recently implemented a reporting program through their electronic medical records (EMR) system in January 2025 for staff to report items needing maintenance. He/She stated the staff have used this system a few times.
2. Review of R70's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease and heart disease.
Review of R70's quarterly Minimum Data Set (MDS), with an assessment reference date of 11/16/24 and located in the MDS tab of the EMR, revealed he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.
During an interview and concurrent observation in R70's room, the walls were covered with screws, nails, chipped paint, holes, and large patches of discolored areas. R70 stated the walls had always looked like that and it bothered him/her.
During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC confirmed the walls remained in disrepair and needed to be addressed.
3. Review of R56's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy.
Review of R56's quarterly MDS, with an ARD of 11/25/24 and located in the MDS tab of the EMR, revealed he/she scored 15 out of 15 on the BIMS, indicating intact cognition.
During an interview and concurrent observation on 02/17/25 at 3:59 PM in R56's room, the mirror above the sink was observed without glass, only the backing, which was non-reflective. R56 stated there was no mirror in the bathroom, so if he/she wanted to see himself/herself in the mirror, he/she had to walk down to the shower room, which bothered him/her. In addition, there were multiple small holes in the wall and several large unpainted patches on the wall. R56 stated, The wall bugs me, it has been like this for a while . I don't know where holes and patches came from; they were here before I came.
During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the missing glass in the mirror and holes and patches on the wall were again observed. The RMC stated the walls had several holes and unpainted areas and stated he would replace the mirror over the sink.
4. During observation of the door exiting to the smoking area on the [NAME] Hall on 02/19/25 at 2:03 PM, the baseboard near the door was peeled off and crumbling concrete, dirt, and one cigarette butt was observed at the base of the wall.
During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC stated the baseboard was still peeling off the wall exposing crumbling concrete and possibly creating access for pests. He/She stated this issue needed to be addressed.
5. Review of R65's Clinical Census, located under the Census tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE], with diagnoses which included spondylosis, osteoarthritis, opioid dependence, major depressive disorder, post-traumatic stress disorder, antisocial personality disorder, anxiety disorder, and chronic pain syndrome.
Review of R94's Clinical Census located under the Census tab of the EMR revealed the resident was admitted on [DATE], with diagnoses which included gastric ulcer, anxiety disorder, and hesitancy of micturition.
During an observation and interview on 02/17/25 at 10:18 AM, R65 was observed wearing a jacket. R94 was observed wearing a sweatshirt and sweatpants. R65 and R94 stated there had been no heat in the room all winter. R65 stated the facility wanted them to move to another room but they did not want to move. R65 stated they did get heat from the hallway with door open to the room. R94 stated they were told heater would be replaced but the facility wants us to move to another room. It was observed that the bathroom for R65 and R94 had a ceiling vent with the cover off, holes in ceiling tiles, and holes in walls.
During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC confirmed the heat was not working in the residents' room and was something he/she would have expected to be addressed immediately, as it was a matter of comfort and health in the cold winter.
6. Observation on 02/17/25 at 10:38 AM, of room [ROOM NUMBER], showed the heater cover was sitting on the floor in front of the heater exposing the inside of the heater, the mirror over the sink was broken, and the closet doors were off the hinges.
During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC confirmed the heater vent cover was not assembled properly and was able to put the cover back in place. The RMC stated that it was an important thing to address, as it could contribute to safety concerns with the heating elements.
7. Observation on 02/17/25 at 11:26 AM, of room [ROOM NUMBER], showed the light cover was broken and hanging down over the resident's bed.
During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC confirmed the light was missing cover and it should be replaced.
Review of the facility's undated policy titled, Safe and Homelike Environment revealed, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment . Report any furniture in disrepair to Maintenance promptly . Report any unresolved environmental concerns to the Administrator.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to implement pest control measures to pre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to implement pest control measures to prevent mouse infestation in the facility, which affected four of 27 sampled residents (Resident (R) 76, R2, R22, and R73) and the common areas of the facility. This failure had the potential to cause an increase in rodent activity, creating a potential for spread of infection and dissatisfaction with living arrangements among the residents.
Findings include:
Review of March 2024 to December 2024 weekly pest control Service Inspection Reports, provided by the facility, revealed ongoing treatment for mice. The reports repeatedly documented the same recommendations for preventing the mice from entering the building. These recommendations included:
-Fixing holes in the walls near several heat registers,
-Fixing holes by baseboards throughout the facility,
-Ensuring kitchen doors were rodent-proofed by eliminating gaps,
-Ensuring gap under the front door was eliminated, and
-Removing trash from around the facility.
Review of the 01/10/25 pest control Service Inspection Report revealed, Inspected interior rodent traps. Found evidence of rodent activity. Recorded capture. All traps accessible and in good condition. Under Open Conditions, the report listed:
1. Condition: kitchen exterior entryway has a gap under the door sweep. - exterior entryway has
concrete that is not level, leaving a 1/2 [inch] gap under the door sweep. [NAME]: use self-leveling concrete and fill the hole. The severity level was high, responsibility was the facility, and the created date for this condition was 08/02/24.
2. Condition: back door area - trash and debris creating harborage opportunity for rodents
Action: Throw trash in dumpsters. The severity level was high, responsibility was the facility, and the created date for this condition was 11/15/24.
Review of the most recent pest control Service Inspection Report, dated 01/16/25 and provided on paper, revealed, Inspected interior rodent traps. Found evidence of rodent activity. Recorded capture . Inspected copy room for mouse sighting. Discovered a hole by the heat register . Inspected the west housekeeping room for mouse sighting. Found holes by the baseboards by the door entrance and outer wall, recommended these get sealed up . Followed up on the conditions of the doors being rodent-proofed and the trash being removed that was sitting against the building by the back entrance door. Removing this trash will prevent rodents from potentially harboring there. Kitchen doors needs to be rodent-proofed, this creates an opportunity for rodents to enter the kitchen. Front door has a gap that creates a potential entry for rodents. Under Open Conditions, the report listed:
1. Condition: kitchen exterior entryway has a gap under the door sweep. - exterior entryway has
concrete that is not level, leaving a 1/2 [inch] gap under the door sweep. [NAME]: use self-leveling concrete and fill the hole. The severity level was high, responsibility was the facility, and the created date for this condition was 08/02/24.
2. Condition: back door area - trash and debris creating harborage opportunity for rodents
Action: Throw trash in dumpsters. The severity level was high, responsibility was the facility, and the created date for this condition was 11/15/24.
3. Condition: kitchen door needs to be rodent proofed please
4. Condition: front door needs to be rodent proofed please.
1. Review of R76's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease.
Review of R76's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/07/25 and located in the MDS tab of the EMR, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.
During an interview on 02/17/25 at 3:27 PM, R76 stated, I saw a mouse last night in the hall. He/She added he/she saw mice all the time and had two mouse traps in his/her room. R76 stated it bothered him/her to have mice in his/her room.
2. Review of R2's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including left-side paralysis following a stroke.
Review of R2's quarterly MDS, with an ARD of 12/21/24 and located under the MDS tab of the EMR, revealed he/she scored 14 out of 15 on the BIMS, indicating intact cognition.
During an interview on 02/17/25 at 4:11 PM in R2's room, R2 stated there were a lot of mouse droppings behind his/her nightstand in his/her room, and he/she saw mice every night in his/her room.
Observation of the floor behind R2's nightstand revealed a large area of the floor covered in mouse droppings. R2 stated the mice ran over his/her feet at night and it bothered him/her.
3. Review of R22's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE] with a diagnosis of left-side paralysis following a stroke.
Review of R22's admission MDS, with an ARD of 11/13/24 and located under the MDS tab of the EMR, revealed he/she scored 14 out of 15 on the BIMS, indicating intact cognition.
During an interview on 02/18/25 at 9:37 AM, R22 stated there were mice in his/her room that came out at night and bothered him/her during the night. He/She stated a dead mouse had been found in his/her room that morning.
4. Review of R73's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease.
Review of R73's admission MDS, with an ARD of 11/19/24, revealed he/she scored 15 out of 15 on the BIMS, indicating intact cognition.
During an interview on 02/18/25 at 9:46 AM, R73 stated there were mice in his/her room that got into a bag of bread he/she kept for making sandwiches. R73 stated it bothered him/her the mice ate his/her food.
During an interview on 02/21/25 at 7:08 PM, the Regional Maintenance Consultant (RMC) stated he/she had just been hired to start implementing the necessary corrective measures to prevent mouse infestation, as the facility had not yet addressed any of the recommendations found in the pest control reports. The RMC stated he/she did not know why any of the recommendations had not yet been addressed and stated he/she would have expected the facility to act on those recommendations when they were first made. The RMC stated the Maintenance Director had been at the facility for about a year and a half and needed training on time management and prioritization.
Review of the facility's policy titled, Pest Control, dated May 2008, revealed, This facility maintains an on-going pest control program to ensure that the building is kept free of insects
and rodents . Garbage and trash are not permitted to accumulate and are removed from the facility daily . Maintenance services assist, when appropriate and necessary, in providing pest control services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on documentation, interview and policy review, the facility reported to the Centers of Medicare and Medicaid (CMS) through mandatory submission of staffing information in the Payroll- Based Jour...
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Based on documentation, interview and policy review, the facility reported to the Centers of Medicare and Medicaid (CMS) through mandatory submission of staffing information in the Payroll- Based Journal (PBJ)excessively low weekend staff. This deficient practice had the potential to allow 112 residents not to receive the care and services required.
Findings include:
Review of the undated facility policy titled, Nursing Services and Sufficient Staff revealed, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines: 1. The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans .
Review of the Staffing Data Report the following:
The third quarter (April 1- June 30, 2024) indicated excessively low weekend staffing.
The fourth quarter (July 1- September 30, 2024) indicated one star staffing rating, excessively low weekend staffing.
During an interview on 02/21/25 at 10:14 AM, the Staffing Coordinator/ Human Resources (SC/HR) was asked about the reports and stated that it has been a battle to meet the staffing needs for the weekends. The SC/HR said they have continuously hired, and staff do not show up.
During an interview on 02/21/25 at 6:33 PM, the Director of Nursing (DON) was asked about the PBJ and scheduling. The DON stated it has been a challenge to get staffing to cover the weekends.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on document review, interview, and facility policy review, the facility failed to ensure eight hours per day of Registered Nurse (RN) coverage. Specifically, the facility reported to the Centers...
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Based on document review, interview, and facility policy review, the facility failed to ensure eight hours per day of Registered Nurse (RN) coverage. Specifically, the facility reported to the Centers of Medicare and Medicaid (CMS) through mandatory submission of staffing information in the Payroll- Based Journal (PBJ), the lack of RN coverage for three out of four quarters (first, second and fourth quarter of 2024). This deficient practice had the potential to allow 112 residents not to receive the care and services required.
Findings include:
Review of the undated facility policy titled, Nursing Services and Sufficient Staff revealed, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines . 8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day,1 day a week.
Review of the Staffing Data Report the following:
The first quarter (October 1- December 31, 2024) indicated No RN hours.
The second quarter (January 1- March 31, 2024) indicated No RN hours.
The fourth quarter (July 1- September 30, 2024) No RN hours.
During an interview on 02/21/25 at 10:14 AM, the Staffing Coordinator/ Human Resources (SC/HR) was asked about the reports. The SC/HR stated it has been difficult to get an RN for night shift. The SC/HR stated they have tried to hire nurses through newspaper, media sites and through the facility website.
During an interview on 02/21/25 at 6:33 PM, the Director of Nursing (DON) was asked about the PBJ and scheduling. The DON confirmed that the facility did not have RN coverage at least eight hours per day for the first, second and fourth quarters in 2024.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, document review and record review, the facility failed to ensure a Certified Dietary Manager (CDM) or other qualified professional was employed by the facility to mana...
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Based on observation, interview, document review and record review, the facility failed to ensure a Certified Dietary Manager (CDM) or other qualified professional was employed by the facility to manage the dietary department when a Registered Dietitian was not employed full-time. Failure to meet this requirement placed all 112 residents receiving foods served by the facility at risk for dissatisfaction with meals, malnutrition and/or a food-borne illness.
Findings include:
1. During an interview on 02/19/25 at 10:00 AM, the Dietary Manager (DM) was asked if they had completed a certification course for dietary managers, he/she stated, No. When asked if he/she had completed any formal training in food and or nutrition services, the DM stated, No and explained he/she had assumed the role after working as a cook in the facility for the past two years.
2. The facility failed to assure food was palatable and served at appetizing temperatures for residents reviewed for food concerns. Additionally, review of the Review of Resident Council Meeting Minutes revealed complaints related to food palatability from five of five months of minutes reviewed.
3. The facility failed to ensure that one resident's preference for a sandwich to be add to the lunch and dinner meals was being honored.
4. The facility failed to ensure foods were stored, prepared, and distributed under sanitary conditions.
During an interview on 02/19/25 at 10:10 AM, the Director of Nursing (DON) stated the DM was not a CDM and did not meet the criteria.
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, Food and Drug Administration (FDA) Food Code and policy review, the facility failed to ensure foods were stored, prepared, and distributed under sanitary conditions. T...
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Based on observation, interview, Food and Drug Administration (FDA) Food Code and policy review, the facility failed to ensure foods were stored, prepared, and distributed under sanitary conditions. This had the potential to 112 of 112 residents who ate food from the kitchen and placed these residents at risk for a food borne illness.
Findings include:
Review of the 2022 Food Code, published by the Food and Drug Administration (FDA) Food Code and accessible at https://www.fda.gov, revealed, . Handwashing sink shall be equipped to provide water at a temperature of at least . (85 degrees F [Fahrenheit]) through a mixing valve or combination faucet .
Review of the facility's policy titled, Food Preparation and Service, revised 04/2019, revealed, . Food and nutrition services [sic] employees prepare and serve food in a manner that complies with safe food handling practices . Appropriate measures are used to prevent cross contamination. These include . cleaning and sanitizing work surfaces . and food-contact equipment between uses, following food code guidelines . Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness . The 'danger zone' for food temperatures is between 41 [degrees Fahrenheit (F)] and 135 [degrees F]. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Proper hot and cold temperatures are maintained during food service . Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays .
1. During the initial tour of the kitchen on 02/17/25 at 9:20 AM, the water at the handwashing sink was noted to be cold after the water ran for 10 minutes. The [NAME] stepped to the sink and washed their hands. When asked if the water got hot, he/she stated yes, and then commented he/she did not have enough time to wait for it to warm up.
A food processor, located on a counter in the kitchen, was noted to have water inside the bowl. The blade was removed, and food residue was inside the blender bowl. The base of the food processor was soiled with dried food splatter. The Dietary Manager (DM) stated the equipment should be washed and clean if on the base.
The can opener was noted to have black colored food residue adhered to the blade, and the base was observed with dried food spills and splash.
The head of the dispenser gun for the juice dispenser was heavily soiled with visible juice pulp and smelled of sour juice. The handle of the device was soiled and sticky to the touch. The DM stated Dietary Aide (DA) 13 was responsible for cleaning the machine. DA13 stated he/she did not remove the cap or soak the head of the dispenser to clean it.
The handle on the microwave was observed with dried food and was sticky. The interior had food spills inside. The DM commented it must have been used last night.
The walk-in refrigerator had one opened and undated box of health shakes. The DM stated the shakes could be served for up to 14 days after being placed in the refrigerator and should have been dated when placed in the refrigerator.
An undated and unlabeled pan with two cooked pork loins was noted in the walk-in refrigerator. The DM stated the pork was cooked the previous day, then refrigerated, and would be served for the noon meal that day.
The temperature of the handwashing sink was checked, after running the water for 10 minutes, a check of the temperature found it only reached 72 degrees F. The temperature did not reach the FDA recommendation for handwashing sinks in food service areas of 85 degrees F.
On 02/19/25, at 9:30 AM, during an interview with the DM, DA12 was observed rinsing soiled dishes and loading them into rack while wearing gloves. After preparing several racks of soiled dishes, DA12 stepped to the clean side of the dish machine and picked up clean water pitchers with the same gloves. The DM was asked about DA12's actions. The DM directed DA12 to wash their hand in the handwashing sink. DA12 doffed his/her gloves, went to the sink, and rinsed his/her hand under the waterspout. DA12 did not use soap or friction to wash his/her hands. The DM observed this and reapproached DA12 and directed him/her to use soap, friction, and water when washing hands.
On 2/19/25 at 11:50 AM, the Assistant Dietary Manager (ADM) was observed testing and documenting temperatures of foods served for the noon meal on a log. After preparing to serve the meal, two additional food items, cheese quesadillas and soup were observed on the steamtable; however, the temperature log did not record temperatures for either item. When asked, ADM tested the temperatures and found the soup was 128 degrees F and the quesadillas were 117 degrees F. ADM stated the items were not hot enough and reheated them.
On 02/20/25 at 11:00 AM, burritos and toasted cheese sandwiches were noted on the tray line. The [NAME] measured their holding temperatures, and it was noted the temperature of both items was 128 degrees F. [NAME] then moved the items to the oven to reheat them.
2. During delivery of room meal trays in the [NAME] Hall on 02/17/25 beginning at 1:09 PM, the meal trays were observed on a metal cart. Each tray had a plate covered with an insulated cover and a small dish containing the apple cobbler dessert, which was not covered. The staff brought the meal trays from the cart at one end of the hall to residents' rooms up and down the length of the hall with the dessert uncovered.
In an interview on 02/17/25 at 1:15 PM, certified nurse aide (CNA) 8 stated the desserts on the trays were not covered because it did not fit under the cover over the main plate. CNA8 stated the dessert was typically served uncovered in a separate dish.
During delivery of room meal trays in the [NAME] Hall on 02/19/25 beginning at 1:36 PM, the meal trays were observed on a metal cart covered with plastic. Each tray had a plate covered with an insulated cover and a small dish containing the muffin dessert, which was not covered. The staff brought the meal trays from the cart at one end of the hall to residents' rooms up and down the length of the hall with the dessert uncovered. The Director of Nursing (DON) served a tray to a resident containing an uncovered dessert.
In an interview on 02/19/25 at 2:06 PM, the DON confirmed the dessert was uncovered while on the uncovered cart and while in transit down the hall.
In an interview on 02/21/25 at 2:31 PM, the DM stated he/she noticed the desserts were not covered again today when going down the hall in the uncovered cart.
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 refuse and garbage was disposed of properly when the lid to the dumpster was not kept closed. This had the potential to increase the r...
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Based on observation and interview, the facility failed to ensure refuse and garbage was disposed of properly when the lid to the dumpster was not kept closed. This had the potential to increase the risk of rodents and other pests which could affect all 112 residents who resided at the facility.
Findings include:
During observations of the dumpsters located behind the kitchen on 02/17/25 at 10:00 AM, 02/18/25 at 10:45 AM, 02/20/25 at 11:45 AM and 2/21/25 at 9:30 AM, the dumpster lid was observed open.
During an interview on 02/17/25 at 10:00AM, the Dietary Manager (DM) reported that all the departments in the facility discarded garbage in the area and should close the lid when they finished adding trash to the dumpster.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview, and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) plan was developed containing the process the facility will follow to guide ...
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Based on interview, and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) plan was developed containing the process the facility will follow to guide the care and services provided to residents and measure improvement. This deficient practice had the potential to not capture the efforts made in measuring the care and services for 112 residents.
Findings include:
Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program- Governance and Leadership revised March 2020 revealed, Policy Statement The quality assurance and performance improvement program are overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body.
During an entrance conference with the facility's Director of Nursing (DON) on 02/17/25 at 9:31 AM and at 4:45PM, a request was made to get the QAPI plan for review.
On 02/18/25 at 2:48 PM and 02/20/25 at 11:00AM, a request was made to the Administrator for the QAPI plan.
On 02/20/25 at 09:44 AM, the Administrator stated. We do not know what a QAPI plan is and have never heard of that before. We do not have a QAPI plan.
During an interview 02/21/25 at 6:33 PM, the DON stated the Administrator was new as of January 2025. There has been only one meeting with staff and that was the passing out of the clinical pathways, that each department head would take what pertains to their department. The group will come together for the next meeting and present their findings. The DON was asked what improvements programs are being worked on. The DON stated he/she could not find the previous meetings with the previous Administrator.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0698
(Tag F0698)
Minor procedural issue · This affected most or all residents
Based on record review, interview and policy review, the facility failed to provide the personalized dialysis contract for one of one resident (Resident (R)31) who received dialysis from the facility....
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Based on record review, interview and policy review, the facility failed to provide the personalized dialysis contract for one of one resident (Resident (R)31) who received dialysis from the facility. This deficient practice had the potential to affect all residents who receive dialysis from this facility to receive agreed on services.
Findings include:
Review of the facility's policy titled, Business Associate Agreements revised February 2014 revealed, Policy Statement: Our facility may disclose protected health information (PHI) (including electronic protected health information [e-PHI]) to business associates or allow business associates to create or receive protected health information (PHI/e-PHI), upon the business associate's signing a written agreement to appropriately safeguard such protected information.
Review of R31' electronic medical record (EMR) revealed an admission Record revealed an admission date of 10/15/24 with diagnosis of end stage dialysis.
Review of R31's quarterly Minimum Data Set (MDS) with an assessment reference date of 01/19/25, with a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated R31 was cognitively intact.
Review of R31's EMR revealed, Physician Orders located under the Orders tab revealed an order dated 10/15/24 for dialysis at [name of facility] on Monday, Wednesday, and Friday.
On 02/18/25 at 9:00 AM, the Director of Nursing (DON) was asked about the dialysis contract. The DON stated they could not find the contract and were waiting to get ahold of the dialysis center to have them send a copy of the contract.
On 02/20/25 at 10:00 AM, another request was made for the dialysis agreement. The Administrator stated they were still waiting for a copy of the agreement from the dialysis center that R31 goes to for dialysis.
On 02/21/25 at 2:00 PM, the DON confirmed that they did not have nor received a contract from the dialysis center.
Dec 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide a written discharge notice to one sampled resident (Resident #2) and/or his/her guardian upon emergency discharge from the facility...
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Based on interview and record review, the facility failed to provide a written discharge notice to one sampled resident (Resident #2) and/or his/her guardian upon emergency discharge from the facility out of five sampled residents. The facility census was 101 residents.
Review of the facility's policy titled Transfer or Discharge Notice dated March 2021 showed residents and/or representatives were notified in writing, and in a language and format they understood, at least 30 days prior to a transfer or discharge.
1. Review of Resident #2's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/9/24 showed the resident was discharged on 10/9/24 and the resident's discharge was unplanned.
Review of a nurse's note dated 10/9/24 at 3:14 P.M. showed the resident had called Emergency Medical Services (EMS) on himself/herself and was transported to a local hospital.
Review of a nurse's note dated 10/9/24 at 6:30 P.M. showed:
-The Director of Nursing (DON) had given verbal emergency discharge notice to Guardian A.
-Guardian A was to be provided the written discharge notice by fax during business hours the following day.
Review of the resident's care plan dated 10/14/24 showed no care plan related to any discharge planning.
Review of the resident's Electronic Medical Record (EMR) on 12/30/24 showed no written discharge notice is the resident's chart.
During an interview on 12/30/24 at 10:09 A.M. the DON said he/she had spoken at length with Guardian A related to the resident's discharge.
During an interview on 12/30/24 at 11:15 P.M. the DON said the previous Administrator had told him/her that he/she had faxed a copy of the resident's written discharge notice to Guardian A.
During an interview on 12/30/24 at 11:26 A.M. Guardian A said he/she was unsure if he/she had received a written discharge notice from the facility. He/she had no record of a written copy of the discharge notice.
During an interview on 12/30/24 at 11:45 A.M. the DON said:
-He/She could not find a copy of the resident's written discharge notice.
-He/She could only verify that a verbal notice had been provided.
During an interview on 12/30/24 at 1:59 P.M. Hospital Social Worker A said he/she was unable to find a written discharge notice in the resident's hospital records.
During an interview on 12/30/24 at 2:29 P.M. Licensed Practical Nurse (LPN) A said:
-He/She was responsible for notifying a resident's Durable Power of Attorney (DPOA) if indicated when a resident discharges to a hospital.
-The verbal notification would be in a nurse/progress note.
-He/She was unsure who completed the written notification of discharge to residents.
-He/She thought that the DON would be responsible for ensuring completion of all parts of the discharge notification process.
During an interview on 12/30/24 at 3:30 P.M. Social Services Designee (SSD) A said:
-He/She had not worked at the facility when the resident discharged from the facility.
-The Administrator would be responsible to completing the written discharge notices and giving them to the residents and/or resident representative.
-Written discharge notices needed to be given at least 30 days prior to the discharge from the facility.
During an interview on 12/30/24 at 4:03 P.M. the DON said:
-A written discharge notification should have been provided to the resident and/or Guardian A.
-The previous Administrator had taken full responsibility for completing and giving all written discharge notices.
-He/She should have followed up with the previous Administrator to ensure that the written notification had been faxed to Guardian A.
During an interview on 1/6/25 at 11:15 A.M. the acting Administrator said:
-He/She had thought that a discharge notice had been sent to Guardian A.
-He/She had looked back through the resident's chart and saw that one was supposed to have been sent, but the facility could not find a copy of it.
-He/She would have expected a written discharge notice to have been sent to Guardian A.
MO00246194
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
Safe Transfer
(Tag F0626)
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 permit one sampled resident (Resident #2) for re-admission to the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit one sampled resident (Resident #2) for re-admission to the facility out of five sampled residents. The facility census was 101 residents.
Review of the facility's policy titled Bed-Hold and Returns dated March 2022 showed:
-A resident would be permitted to return to an available bed in the location of the facility that he or she previously resided in.
-If there was not an available bed in that part, the resident would be given the option to take the available bed in another distinct part of the facility and return to the previous distinct part when a bed were to become available.
1. Review of Resident #2's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/9/24 showed the resident was discharged on 10/9/24 and his/her return was not anticipated.
Review of a nurse's note dated 10/9/24 at 3:14 P.M. showed the resident had called Emergency Medical Services (EMS) on himself/herself and was transported to a local hospital.
During an interview on 12/6/24 at 11:05 A.M. Guardian A said:
-The resident had been given an immediate discharge notice.
-The resident was ready for discharge at that time from the hospital.
-No other facilities had accepted him/her and the resident should be allowed back to the facility.
-He/she had spoken with a previous Administrator who informed him/her that the facility would not be taking the resident back.
During an interview on 12/20/24 at 10:09 A.M. the Director of Nursing (DON) said that the facility could no longer meet the needs of the resident and that was why he/she could not be re-admitted to the facility.
During an interview on 12/30/24 at 11:26 A.M. Guardian A said:
-The resident was still at the same local hospital the resident discharged to from the facility on 10/9/24.
-The hospital had sent mass referrals to other facilities in the State, but all facilities had denied placement.
During an interview on 12/30/24 at 1:52 P.M. Guardian A said:
-He/She had been told by a previous Administrator that the facility could no longer meet the needs of the resident and that was why the facility denied re-admission to the facility.
-During that conversation with the previous Administrator, the Administrator told him/her that the facility was willing to risk getting a citation and had been adamant about not letting the resident back into the facility.
During an interview on 12/30/24 at 1:59 P.M. Hospital Social Worker A said:
-The DON had told the Emergency Department (ED) social worker that the facility would not be accepting the resident back on 10/9/24.
-The facility also declined the referral back to the facility on [DATE], 11/13/24, and 12/5/24.
During an interview on 12/30/24 at 2:29 P.M. Licensed Practical Nurse (LPN) A said he/she was unaware that the resident had not been allowed back into the facility.
During an interview on 12/30/24 at 2:55 P.M. the Director of Admissions said:
-He/She had not worked at the facility prior to the resident's discharge and initial referrals to the facility.
-He/She was aware that the facility was not allowing the resident to be re-admitted to the facility.
-He/She had been told by the Administrator and DON that the resident was not allowed back to the facility.
-The Clinical Team and the Business Office Manager (BOM) were responsible for reviewing referrals for admission to the facility.
During an interview on 12/30/24 at 3:30 P.M. the Social Services Designee (SSD) said:
-The facility would be responsible for ensuring the resident was allowed to re-admit to the facility.
-The facility was going against the regulation.
-He/She had not worked at the facility prior to the resident's discharge and was unaware of the situation.
During an interview on 13/20/24 at 4:03 P.M. the DON said:
-Per regulation, he/she understood that the resident was to be re-admitted to the facility.
-He/She, the Administrator and the clinical team were responsible for denying the resident to be re-admitted to the facility.
-He/She was not willing to re-admit the resident to the facility.
During an interview on 1/6/25 at 9:33 A.M. the Acting Administrator said:
-All referrals go to the Director of Admissions, then the clinical team and BOM would be responsible for accepting or denying the referral.
-The Administrator was the person who made the final decision on referrals.
-He/She agreed with the previous Administrator's decision to not accept the resident back.
-He/She was unaware that the hospital made attempts to refer the resident back to the facility prior to the 30 days.
-He/She thought the hospital had only sent a referral in December.
-He/She understood the regulation, but the resident had been discharged from the facility for more than 30 days, so the resident would need a whole new referral and was not the facility's responsibility at that time.
CMP # MO00246194
Nov 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the guardian, emergency contact and/or physician for one sam...
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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 guardian, emergency contact and/or physician for one sampled resident (Resident #7) when on 10/30/24 the resident did not return to facility out of seven sampled residents. The facility census was 105 residents.
Review of the facility Wandering and Elopement Policy dated 3/2019 showed:
-If a resident is missing, initiate the elopement/missing resident emergency procedure.
-Determine if the resident is out on an authorized leave or pass.
-If the resident was not authorized to leave, initiate a search of the building and premises.
-If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies.
Review of the facility Leave of Absence Policy dated 4/1/22 showed:
-Leave of Absence (LOA) defined as leaving the facility with the appropriate authorization and notification.
-A resident who is cognitively intact with independent decision making with a physician's order may sign themselves out for a LOA.
-In the event the resident exits the facility without signing out on the log, the facility will initiate an investigation to locate the resident.
-For residents that sign out for a LOA the resident/family/responsible party will indicate the anticipated time of return at the time they sign out.
-Contact the resident/family/responsible party if they have not returned within on hour of the anticipated return time.
-Notify the Executive Director if unable to contact the resident/family/responsible party, or if they refuse to return.
-Resident will return to the facility no later than 8:00 P.M. unless approved by the physician and left with the appropriate medications.
Review of the facility Notification of Changes Policy dated, 8/24 showed:
-The purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician; and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification.
-The facility must inform the resident, consult the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.
--Accidents resulting in injury.
--A transfer or discharge of the resident from the facility.
-Competent individuals:
--The facility must still contact the resident's physician and notify the resident representative if known.
-Contact information of the resident's legal representative or family member must be recorded and periodically updated.
1. Review of Resident #7's admission Record showed the resident was admitted on [DATE] with a legal guardian and diagnoses including sickle-cell disorder with crisis (a group of inherited disorders that affects the shape of red blood cells with sickle cell crisis - painful episode that occurs when sickle-shaped red blood cells block blood flow to organs, muscles, and bones) and schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others).
Review of the resident's undated Care Plan showed:
-The resident has no leave of absence per physician orders dated 10/24/23.
--All appointments to be scheduled with staff escort.
--Keep staff and residents updated on changes to order.
--Notify physician if leave of absences occur.
During an interview on 11/6/24 at 7:18 P.M., the resident's guardian said:
-On 11/6/24 at 3:00 P.M. during a call with a specialty clinic out of state for the resident's sickle-cell disease, he/she discovered the resident was not at the facility and was out of the state.
-The resident was to have a treatment on 10/30/24 for his/her sickle-cell and signed him/herself out of the facility to attend the appointment, the resident never returned to the facility and the facility failed to notify him/her the resident had not returned.
-Due to the resident's severe schizophrenia, the resident was supposed to be supervised for all medical appointments.
-He/She had given permission for the resident to walk to the corner store.
During an interview on 11/12/24 at 10:15 A.M., the Interim Administrator said:
-The facility did not notify the guardian when the resident went missing.
-The resident had an appointment on 10/30/24, but it was postponed.
-The resident decided to sign him/herself out of the facility.
-The nurse was under the impression the resident had went to his/her scheduled treatment; when the resident did not return, the staff presumed the resident was in the hospital.
-None of the staff called the treatment facility or any hospitals to locate or confirm where the resident was at any time, including the Administrator.
During an interview on 11/13/24 at 10:45 A.M., the Interim Administrator said the resident was missing from the facility for seven days before the he/she was notified by the Director of Nursing (DON).
During an interview on 11/13/24 at 10:53 A.M., the DON said:
-He/She was contacted on 11/6/24 by the resident's guardian and the guardian reported the resident was out of the state.
-The resident had left the faciity on [DATE] and the nurse thought the resident was going to his/her scheduled treatment.
-The resident signed him/herself out of the facility and did not return.
-Typically the resident would return to the facility within a few hours.
-Normally the staff would follow up with the hospital to verify the resident had been admitted or the hospital would call to inform the facility the resident had been admitted .
-The nurse should have called to verify where the resident was the evening of 10/30/24 when the resident had not returned before dark.
-The guardian and physician should have also been notified.
During an interview on 11/13/24 at 2:00 P.M., the Nurse Practitioner said:
-There was no notification of the resident leaving the facility and not returning.
-Although the resident often left for treatments and ended up in the hospital, there needed to be some changes to ensure the resident was actually hospitalized and not missing for seven days unnoticed.
-He/She expected staff to follow up and ensure the resident's location.
During an interview on 11/13/24 at 2:59 P.M., the Administrator said:
-There should have been an accident/incident report completed.
-When the resident was out of the facility it was presumed he/she was in the hospital.
-He/She was not aware the resident was missing until the guardian contacted the DON on 11/6/24.
-He/She expected the nurse to follow up on the location of the resident.
-Once the location of the resident had been verified the guardian and the physician should have been notified.
During an interview on 11/13/24 at 2:00 P.M., the Nurse Practitioner said:
-There was no notification the resident left the facility and had not returned on 10/30/24.
-He/She expected staff to ensure safety and notify the provider as soon as possible.
During an interview on 11/13/24 at 2:59 P.M. the Administrator said:
-He/She expected the guardian and physician to be notified when the resident did not return to the facility on [DATE], no matter where the resident was or was not located.
MO00244765
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the physical abuse of three sampled residents (Resident #4,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the physical abuse of three sampled residents (Resident #4, #5 and #6). On 11/2/24 Family Member A entered the facility visibly and verbally upset stating to call 911 as he/she had been robbed. Receptionist A let Family Member A into the building. Family Member A began down the hall. Certified Nurse Aide (CNA) A followed Family Member A to ask why 911 should be called. Before CNA A could get an answer, Family Member A entered Resident #1 and Resident #2's room. Family Member A then went to Resident #1's side of the room struck Resident #3 and Resident #1 in the face and mouth area. Then Family Member A went to the bedside of Resident #2 where the resident was sleeping and struck Resident #2 in the face. Family Member A struck all three residents in the face or mouth area causing all three of them to have minor lacerations and bruising documented in their chart where first aid was provided out of seven sampled residents. The facility census was 105 residents.
Review of the facility Abuse, Neglect, Exploitation or Misappropriation Prevention Program Policy dated 4/2024 showed:
-Protect residents from abuse by anyone including visitors.
-Provide orientation and training programs that include topics such as abuse prevention, identification and reporting abuse.
-Establish and implement a Quality Assurance Performance Improvement (QAPI review and analysis of reports, allegations or findings of abuse).
Review of the facility Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation Policy dated 4/2024 showed:
-The individual conducting the investigation as a minimum includes:
--Interviews with the resident's attending physician as needed to determine the resident's condition.
--Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident.
1. Review of Resident #4's admission Record showed the resident was admitted on [DATE] with diagnoses including schizophrenia and psychoactive substance use.
Review of Resident #4's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/15/24 showed the resident was cognitively intact.
Review of Resident #5's admission Record showed the resident was admitted on [DATE] with diagnoses including cocaine abuse and chronic pain syndrome.
Review of Resident #5's admission MDS dated [DATE] showed the resident was cognitively intact.
Review of Resident #6's admission Record showed the resident was admitted on [DATE] with diagnoses including frostbite to the left and right foot, and need for assistance with personal care.
Review of Resident #6's admission MDS dated [DATE] showed the resident was cognitively intact.
Review of Resident #4's Nurse's Note dated 11/2/24 at 5:49 P.M. showed:
-Skin assessment completed after a visitor hit the resident in the mouth.
-The resident had a cut on the inside of his/her upper lip.
-The resident denied pain.
Review of Resident #5's Nurse's Note dated 11/2/24 at 2:43 P.M. showed:
-Skin assessment done after a visitor hit him/her in the mouth.
-The resident had a cut on his/her upper lip.
-The resident denied pain.
Review of Resident #6's Nurse's Note dated 11/2/24 at 2:26 P.M. showed:
-The resident was involved in a resident to visitor altercation and got hit in his/her upper lip.
-The resident complained of pain 6 out of 10.
-The resident reported he/she was in another resident's room when the visitor came in the room and hit him/her in his/her face. I was in the wrong place and the wrong time. I have done nothing wrong.
Review of the facility Summary of Abuse dated 11/3/24 showed:
-Family Member A was visiting Resident #4 on 11/2/24.
-Family Member A had left and returned to the facility on [DATE] stating Call the police, I have been robbed.
-Upon returning to the facility on [DATE], Family Member A went to Resident #4's room and struck Resident #6, then Resident #4 and then Resident #5.
-Resident #5 was sleeping at the time of the incident.
-CNA A removed Family Member A from the room.
-Law enforcement was contacted.
-Family Member A was arrested.
-All three resident sustained lip injuries as a result of the incident.
-Resident #6 pressed charges for assault.
-The allegation of abuse was substantiated by the facility.
During an interview on 11/12/24 at 2:03 P.M. Resident #4 said:
-Family Member A came to the facility on [DATE] and the staff let him/her in the facility.
-The facility had not been letting Family Member A in because he/she got into an argument with staff.
-Family Member A had left and the staff let him/her in for a second time on 11/2/24.
-Family Member A was upset about missing money and thought he/she and Resident #5 were responsible for taking the missing money.
-Upon entering his/her room, Family Member A struck Resident #6, then struck him/her, then went to the bedside of Resident #5, who was sleeping, and struck Resident #5.
-Everyone was straight (not under the influence of any substance) that day.
-The bruising present on his/her lip was from being struck by Family Member A.
-Family Member A was not supposed to be let in the facility as they were supposed to visit at the front common area.
-The incident would have been prevented if staff had not allowed Family Member A into the facility.
During an interview on 11/12/24 at 1:24 P.M. Resident #5 said:
-He/She and Resident #4 were roommates on 11/2/24.
-Resident #4's sibling, Family Member A, came to visit and was talking about going somewhere warmer for the winter.
-He/She was trying to help Family Member A make travel arrangements and allowed Family Member A to use his/her phone.
-He/She did not hear Family Member A get a confirmation for arranging travel to California.
-Family Member A left and then returned after lunch on 11/2/24.
-When Family Member A came into the room he/she struck Resident #6 and Resident #4, then came to his/her bedside and struck him/her on the mouth while he/she was sleeping.
-Staff came in and escorted Family Member A out of the room.
-Law enforcement came, interviewed him/her and arrested Family Member A.
-He/She believed Family Member A was under the influence of substances and did not press charges.
-He/She feels safe in the facility as long as Family Member A is not allowed to return to the facility.
-He/She had a split top lip which was painful for several days after the incident.
During an interview on 11/12/24 at 1:50 P.M. Resident #6 said:
-He/She got hit while in Resident #4's room.
-Family Member A came into the room and hit him/her in the mouth.
-He/She pressed charges and has an upcoming court date.
He/she got a split lip from being hit by Family Member A.
-Family Member A was escorted out of the facility in the past for passing dope in the facility.
-He/She felt the incident would have been prevented if the staff had not allowed the resident in the facility.
During an interview on 11/13/24 at 11:33 A.M. the DON said:
-He/She expected the staff to not allow visitors that were upset on the floor with the residents.
-The staff up front should have intervened with Family Member A.
-He/She was unable to locate the accident/incident reports for Resident #4, #5, and #6.
During an interview on 11/13/24 at 11:45 A.M. the Interim Administrator said:
-He/She does not expect staff to physically restrain any visitor, but to call law enforcement when needed.
-Any staff is able to access the doors to allow visitors enter, especially during the overnight and weekends.
During an interview on 11/13/24 at 12:00 P.M. CNA A:
-He/She was up front on 11/2/24 when Family Member A entered the facility.
-Upon entering the facility around 12:45 P.M. on 11/2/24, Family Member A was saying, Call 911. I've been robbed.
-Family Member A appeared to be in a rush as he/she went down the hall towards Resident #4's room.
-He/She initially thought the resident was headed to his/her family's room to let his/her family know he/she had been robbed.
-He/She felt he/she needed to go check on Family Member A and find out what exactly was going on.
-By the time he/she approached Resident #4's room, he/she could hear resident's yelling out from the room.
-As he/she entered the room, he/she observed that all three residents in the room (Resident #4, #5, and #6) had all been hit and Family Member A was standing next to the entry yelling, Get my money.
-He/She escorted Family Member A out of the room and to the front exit.
-He/She was aware Family Member A was to be supervised when carrying a bag.
-He/She observed all three residents (Resident #4, #5, and #6) had busted lips.
-Law enforcement was at the facility quickly and arrested Family Member A for assaulting the residents.
-Only Resident #5 wanted to press charges as he/she was very upset about being hit.
During an interview on 11/13/24 at 12:54 P.M. Licensed Practical Nurse (LPN) A said:
-He/She was working on the other side of the facility when he/she heard a commotion on 11/2/24 at approximately 12:45 P.M.
-He/She ran to see what was going on and observed Family Member A yelling as he/she was being escorted away and Resident #4 with a blood mouth.
-He/She provided first aide to Resident #4 and Resident #5. Another nurse provided first aide to Resident #6.
-He/She contacted the DON and the administrator about the three residents being assaulted by Family Member A.
-He/She could not recall speaking with the medical director about the assault on Resident #4, #5 and #6.
-He/She felt like Family Member A hitting Resident #4, #5 and #6 was abuse.
During an interview on 11/13/24 at 1:30 P.M. CNA B said:
-He/She was working on the other side of the facility when he/she heard some commotion on the other side on 11/2/24 at approximately 12:45 P.M.
-When he/she got to Resident #4's room he/she could hear the staff saying Family Member A had to go.
-He/She assisted with escorting Family Member A out of the facility.
-Family Member A hit all three residents in the same spot, on the mouth.
-Although Family Member A was upset over money, it did not justify hitting anyone.
During an interview on 11/13/24 at 2:00 P.M. the Nurse Practitioner said:
-He/She felt like the incident on 11/2/24 in which Resident #4, #5 and #6 were assaulted by Family Member A meets the criteria for abuse.
-He/She visualized all three residents on 11/13/24 and had no concerns related to injuries.
-The injuries sustained from the assaults were minor and required first aid.
-He/She expected staff to ensure safety and notify the provider as soon as possible.
-The incident on 11/2/24 may have been prevented by keeping Family Member A in a safe place to watch.
During an interview on 11/13/24 at 2:59 P.M. the Administrator said:
-He/She was notified immediately of the incident on 11/2/24 by the DON.
-He/She was not aware of the potential need for Family Member A to be supervised while in the facility.
-He/She expected staff to remove any visitors displaying suspicious behavior.
-When Family Member A entered the building on 11/2/24 at approximately 12:45 P.M. stating he/she had been robbed, the staff could have stopped Family Member A and asked question.
-He/She feels the incident on 11/2/24 meets the criteria for abuse at face value, but the facility did not do anything wrong.
-There had been no training, education or in-services related to the incident.
-As a part of the risk management and tracking the facility should have completed an accident/incident report for each resident assaulted on 11/2/24.
MO 00244552
MO 244766
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to take corrective action which included physician notification, 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 take corrective action which included physician notification, staff education, staff training and or staff in-services after physical abuse of three sampled residents (Resident #4, #5 and #6) out of seven sampled residents. The facility census was 105 residents.
Review of the facility Abuse, Neglect, Exploitation or Misappropriation Prevention Program Policy dated 4/2024 showed:
-Protect residents from abuse by anyone including visitors.
-Provide orientation and training programs that include topics such as abuse prevention, identification and reporting abuse.
-Establish and implement a Quality Assurance Performance Improvement (QAPI review and analysis of reports, allegations or findings of abuse).
Review of the facility Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation Policy dated 4/2024 showed:
-The individual conducting the investigation as a minimum includes:
--Interviews with the resident's attending physician as needed to determine the resident's condition.
--Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident.
-Corrective action may include a full review of the incident by a QAPI committee.
1. Review of Resident #4's admission Record showed the resident was admitted on [DATE] with diagnoses including schizophrenia and psychoactive substance use.
Review of Resident #4's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/15/24 showed the resident was cognitively intact.
Review of Resident #5's admission Record showed the resident was admitted on [DATE] with diagnoses including cocaine abuse and chronic pain syndrome.
Review of Resident #5's admission MDS dated [DATE] showed the resident was cognitively intact.
Review of Resident #6's admission Record showed the resident was admitted on [DATE] with diagnoses including frostbite to the left and right foot, and need for assistance with personal care.
Review of Resident #6's admission MDS dated [DATE] showed the resident was cognitively intact.
Review of the facility Summary of Abuse dated 11/3/24 showed:
-Family Member A was visiting Resident #4 on 11/2/24.
-Family Member A had left and returned to the facility on [DATE] stating Call the police, I have been robbed.
-Upon returning to the facility on [DATE], Family Member A went to Resident #4's room and struck Resident #6, then Resident #4, then Resident #5.
-Resident #5 was sleeping at the time of the incident.
-Certified Nursing Assistant (CNA) A removed Family Member A from the room.
-Law enforcement was contacted.
-Family Member A was arrested.
-All three residents sustained lip injuries as a result of the incident.
-Resident #6 pressed charges for assault.
-The allegation of abuse was substantiated by the facility.
During an interview on 11/13/24 at 11:33 A.M. the Director of Nursing (DON) said:
-He/She expected the staff to not allow visitors that were upset on the floor with the residents.
-The staff up front should have intervened with Family Member A.
-He/She was unable to locate the accident/incident reports for Resident #4, #5, and #6; in addition he/she provided no additional staff education, training or in-servicing on abuse.
During an interview on 11/13/24 at 2:00 P.M. the Nurse Practitioner said:
-He/She felt like the incident on 11/2/24 in which Resident #4, #5 and #6 were assaulted by Family Member A meets the criteria for abuse.
-He/She visualized all three residents on 11/13/24 and had no concerns related to injuries.
-The injuries sustained from the assaults were minor and required first aid.
-He/She expected staff to ensure safety and to notify the provider as soon as possible.
During an interview on 11/13/24 at 2:59 P.M. the Administrator said:
-He/She was notified immediately of the incident on 11/2/24 by the DON.
-He/She was not aware of the potential need for Family Member A to be supervised while in the facility.
-He/She expected staff to remove any visitors displaying suspicious behavior.
-When Family Member A entered the building on 11/2/24 at approximately 12:45 P.M. stating he/she had been robbed, the staff could have stopped Family Member A and asked questions.
-He/She feels the incident on 11/2/24 meets the criteria for abuse at face value, but the facility did not do anything wrong.
-There had been no staff training, education or in-services related to the incident.
-As a part of the risk management and tracking the facility should have completed an accident/incident report for each resident assaulted on 11/2/24 and an all staff education, training and in-services on abuse should have been conducted.
MO00244552
MO00244766
Oct 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
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 one sampled resident's (Resident #3) dignity was maintained ...
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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 one sampled resident's (Resident #3) dignity was maintained when on 9/30/24 Certified Nursing Aide (CNA) B pulled the resident's pants down exposing his/her buttocks to other bystanders out of four sampled residents. The facility census was 105 residents.
Review of the facility's Dignity policy dated 2/2021 showed:
-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
-Residents are treated with dignity and respect at all times.
-The facility culture support dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs.
-This begins with the initial admission and continues throughout the resident's facility stay.
-Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
-Demeaning practices and standards of care that compromise dignity are prohibited.
-Staff are expected to treat cognitively impaired residents with dignity and sensitivity.
1. Review of Resident #3's admission Record showed the resident was admitted on [DATE], readmitted on [DATE] with diagnoses including residual schizophrenia and repeated falls.
Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 7/10/24 showed the resident was cognitively intact.
Review of the resident's undated Care Plan showed:
-The resident was physically aggressive related to poor impulse control and poor coping skills.
-The resident had been verbally aggressive to staff and residents.
-When the resident becomes agitated, staff should intervene before agitation escalates.
-Staff should guide the resident away from source of distress and engage the resident calmly in conversation; if the resident response was aggressive, staff were to walk calmly away and approach later.
Review of the Facility Investigation dated 10/7/24 showed:
-The Regional Director and Director of Nursing (DON) were made aware on 10/3/24 at 8:30 A.M. that on 9/30/24 CNA B pulled the resident's pants down when he/she was trying to leave the facility during an episode of aggression.
-Investigation conducted by interviews with all potentially involved parties and review of facility cameras.
-It was determined CNA B was observed on the facility camera pulling the resident's pants down and CNA C witnessed the event.
-CNA B was terminated due to pulling the resident's pants down as alleged.
-CNA C was terminated due to witnessing the event and failed to report to supervisors.
During an interview on 10/3/24 at 10:38 A.M., the DON said:
-He/she was made aware on 10/3/24 that CNA B pulled the resident's pants down while the resident was trying to leave the facility during an episode of aggression.
-He/She was initiating the investigation and prepared to report the allegations per regulatory guidelines.
-The investigation had just begun, however, the plan was to terminate the CNA once he/she came in for an interview with him/her and the Regional Director.
During an interview on 10/3/24 at 11:19 A.M., the Regional Director said:
-He/She was made aware on 10/3/24 that CNA B pulled the resident's pants down.
-He/She expected staff to respect the dignity of the residents at all times.
During an interview on 10/3/24 at 12:00 P.M., the resident said:
-He/She tried to leave the facility by the front entrance and had his/her back to the staff.
-While trying to get out the doors, someone pulled his/her pants down exposed his/her buttocks.
-He/She heard someone laughing when his/her pants were pulled down.
-He/She could not see who pulled down his/her pants, but could name all staff that were in the area at the time.
-He/She felt uncomfortable and embarrassed during the incident.
-He/She said pulling down his/her pants was uncalled for.
During an interview on 10/3/24 at 3:04 P.M., the DON said:
-The facility video footage showed CNA B pulled the resident's pants down.
-The resident was at the front door of the facility trying to exit.
-CNA B is seen on the video standing up from a chair and then pulling the resident's pants down, exposing the resident's buttocks.
During an interview on 10/3/24 at 3:50 P.M. with DON, CNA C said:
-He/She observed the resident attempting to get out of the facility on 9/30/24.
-He/She did not attempt to engage with the resident or any other the staff.
-He/She observed CNA B coming in contact with the resident.
-The DON said the camera showed he/she was as a witness to CNA B pulling the resident's pants down, exposing the resident's buttocks.
-He/She did not intervene or report the incident to anyone.
During an interview on 10/3/24 at 4:31 P.M. with DON, CNA B said:
-He/She was assigned to the resident for one on one monitoring (one person assigned to monitor) due to self-harming behaviors earlier on 9/30/24.
-He/She observed the resident trying to get out the front door.
-He/she denied pulling the resident's pants down purposefully.
-He/She pulled on the resident's pants while the resident was standing at the front door to move the resident back and in the process the resident's buttocks was exposed.
-The DON stated he/she was observed on camera him/her pulling the resident's pants down, exposing the residents buttocks.
MO00242964
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the call light system which resulted in one s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the call light system which resulted in one sampled resident's (Resident #2) call light not being answered for approximately 20 minutes out of four sampled residents. The facility census was 105 residents.
Review of the facility Supporting Activities of Daily Living policy dated 3/2018 showed:
-Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
-Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Review of the facility Answering the Call Light policy dated 3/2021 showed:
-The purpose of this procedure is to ensure timely responses to the resident's requests and needs.
-When answering from the call light station, turn off the signal light.
-Identify yourself and politely respond to the resident by his/her name, Mr./Mrs. Name, how may I help you?
--If the resident needs assistance, indicate the approximate time it will take for you to respond.
--If the resident's request requires another staff member, notify the individual.
--If the resident's request is something you can fulfill, complete the task within five minutes if possible.
--If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, as the nurse supervisor for assistance.
-If assistance is needed when you enter the room, summon help by using the call signal.
1. Review of the facility call light company's maintenance invoice dated 7/8/24 showed:
-On 7/2/24 CAT (a communication system used along with a call light system to notify staff that a light is on) phones not connecting to the server, technician came onsite and was able to correct the settings.
-On 7/3/24 keyboard/mouse combo was purchased and installed onsite.
Review of the facility's Call Light Log dated 10/1/24 showed:
-Seven out of 48 activated call lights went unanswered for 20 to 30 minutes.
-Four out of 48 activated call lights went unanswered for 30 to 60 minutes.
-Five out of 48 activated call lights went unanswered for 60 to 706 minutes.
Review of the facility's Call Light Log dated 10/2/24 showed:
-Three out of 35 activated call lights went unanswered for 20 to 30 minutes.
-Seven out of 35 activated call lights went unanswered for 30 to 60 minutes.
-Six out of 35 activated call lights went unanswered for 60 to 260 minutes.
Review of the facility's Call Light Log dated 10/3/24 showed:
-Three out of 59 activated call lights went unanswered for 20 to 30 minutes.
-Three out of 59 activated call lights went unanswered for 30 to 60 minutes.
-Six out of 59 activated call lights went unanswered for 60 to 237 minutes.
2. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including ventricular tachycardia (rapid heart rate), chronic obstructive pulmonary disease (chronic lung disease) and repeated falls.
Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/18/24 showed the resident was cognitively intact.
Review of the resident's undated Care Plan showed:
-The resident had an ADL self-care performance deficit related to alcohol abuse, anxiety, asthma, chronic back pain, depression, repeated falls, personality disorder, and cardiac disease.
-The resident required supervision for ADLs.
-The resident was at risk for falls related to psychotropic medications.
--The resident will be free of falls.
---Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.
---Follow facility protocol.
During an interview and observation on 10/3/24 from 1:32 P.M., to 1:58 P.M. the resident said:
-The call lights don't work.
-The resident's call light was activated.
-The Activities Director came to the resident's room to invite him/her to an activity and was not aware the call light was activated.
-Licensed Practical Nurse (LPN) A came to the resident's door, but was unaware the resident's call light was activated.
-The resident felt ignored and like his/her needs were not important to the staff and they don't care about him/her.
During an interview on 10/3/24 at 1:57 P.M., the Activity Director said:
-He/She was unaware the resident's call light was activated when she stopped by.
-He/She was unable to see the activated light because it was hidden behind the divider curtain in the room from the doorway, the light above the door was not working and there was no sound.
-He/She did not have a CAT phone.
During an interview on 10/3/24 at 1:58 P.M., LPN A said:
-He/She was unaware of the resident's call light being on when he/she stopped by.
-The only place the call lights alert was at the nurses station.
-He/She was not able to tell when call light was activated even while at the resident's doorway.
-There was no sound, or light over the door and the activated light in the room was behind the divider curtain.
-He/She did not have a CAT phone.
-He/She did not know why the call light had not been answered for the last 20 minutes.
-He/She expected the call light should have been answered.
During an interview on 10/3/24 at 2:34 P.M., the Maintenance Director said:
-He/She was not aware the call system was down.
-The call lights alert only at the nurse's station.
-The indicator lights on the outside of the rooms do not work.
-The system will alert on the CAT phone when the system was working.
-He/She was not sure if the CAT phones were working.
-The nurses and Certified Nurse's Aides (CNA) were responsible for ensuring the CAT phones were charged and working.
-He/She was not responsible for the repair or maintenance of the CAT phones.
-If the CAT phones were not working then staff were supposed to go to the Staffing Coordinator or the Director of Nursing (DON).
-The CAT phones were unavailable and not in use at this time.
During an interview on 10/3/24 at 2:40 P.M., the DON said:
-The CAT phones were not in use.
-He/she requested the Maintenance Director to locate and test the three CAT phones for the building.
During an interview on 10/3/24 at 3:04 P.M., the Regional Director said:
-He/She was unaware of the current call light system was not being used.
-He/she expected call lights to be answered according to policy and regulatory guidelines.
During an interview on 10/8/24 at 3:43 P.M., the DON said:
-The CAT phones were not in use prior to 10/3/24.
-He/She expected call lights to be answered within five to 10 minutes, but no longer than 20 minutes.
-He/She was not aware call lights were being left unanswered more than 20 minutes.
-All call lights not answered in 20 minutes or less was outside the expectation.
-Staff were expected to carry CAT phones to respond to call lights.
-All staff were expected to answer call lights.
MO00242992
Mar 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 appropriate weight management for two sampled residents (Res...
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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 appropriate weight management for two sampled residents (Resident #8 and Resident #10), who had Percutaneous Endoscopic Gastrostomy (PEG) tubes (a tube that is passed into a person through the abdominal wall, commonly used to provide a means of feeding when oral intake is not adequate), with weight discrepancies out of 10 sampled residents. The facility census was 101 residents.
Review of the facility's policy titled Weight Assessment and Intervention dated March 2022 showed:
-Residents are weighed upon admission and at intervals established by the interdisciplinary team.
-Any weight change of five percent or more since the last weight assessment is retaken the next day for confirmation.
-If the weight is verified, nursing will immediately notify the dietician in writing.
-Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time.
1. Review of Resident #8's Face Sheet showed he/she admitted to the facility with the following diagnoses:
-Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors).
-Dysphagia (difficulty or discomfort in swallowing).
-Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
Review of the resident's weights and vitals summary dated 12/12/23 showed the resident weighed 171 pounds (lbs.).
Review of the resident's weights and vitals summary dated 1/15/24 showed the resident weighed 150 lbs, which is a 21 lbs weight loss in 34 days.
Review of the resident's care plan dated 1/30/24 showed:
-The resident was at potential nutritional risk due to Parkinson's and DM II diagnoses, difficulty swallowing, and now used a PEG tube with a history of significant weight loss with the following interventions:
--Registered Dietician (RD) to evaluate and make diet change recommendations as needed (PRN).
--RD would monitor weight, labs, wound healing, hydration, and nutritional status monthly or PRN.
--Weights per facility protocol.
Review of the resident's weights and vitals summary dated 2/7/24 showed the resident weighed 154 lbs, which was weight gain of four pounds in 23 days
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 2/20/24 showed:
-The resident was cognitively intact.
-The resident did not have a swallowing disorder.
-The resident did not have any weight loss.
-The resident only received tube feeding.
- The resident received 51% of his/her proportion of calories through a feeding tube.
-The resident received 500 cubic centimeters (cc- also equivalent to milliliters (ml)) average fluid intake via tube feeding.
Review of the resident's March 2024 Physician Order Sheet (POS) showed:
-A physician's order for a full liquid diet (made up of only fluids) with regular texture, nectar-thick (easily pourable and comparable to heavy syrup), juices only at nectar thick ½ teaspoons (tsp) sips, give sips slowly, allow to do hard swallows in between, to be done by charge nurse or restoration aide (RA) only for diet.
- A physician's order for Jevity (a fiber-fortified tube feeding formula) 1.5, give one can via PEG tube [NAME] times a day for nutritional supplement.
NOTE: No order was found related to the resident being weighed more frequently due to weight changes.
2. Review of Resident #10's Face Sheet showed he/she was first admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses:
-Paraplegia (paralysis of the legs and lower body).
-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses).
-Unspecified Severe Protein-Calorie Malnutrition.
-Dysphagia.
Review of the resident's weights and vitals summary dated 9/7/23 showed the resident weighed 146.2 lbs.
Review of a nutrition/dietary noted dated 12/3/23 completed by the facility's RD showed:
-The resident had not been weighed since September 2023.
-The resident needed to be weighed at least monthly.
Review of a nutrition/dietary note dated 12/6/23 completed by the facility's RD did not indicate if the resident's weight was stable.
Review of the resident's care plan dated 12/12/23 showed:
-The resident required tube feeding related to dysphagia with an intervention to see MD orders for current feeding orders.
NOTE: No care plan focus or intervention was found related to weight management.
Review of the resident's weights and vitals summary dated 12/12/23 showed the resident weighed 130 lbs.
NOTE: The resident was not weighed in October or November.
Review of the resident's quarterly MDS dated [DATE] showed:
-The resident had moderately impaired cognition.
-The resident did not have a swallowing disorder.
-The resident did not have any weight loss.
-The resident had a mechanically altered diet.
-The resident received 51% of his/her proportion of calories through a feeding tube.
-The resident received 500 cc average fluid intake via tube feeding.
Review of the resident's weights and vitals summary dated 1/15/24 showed the resident weighed 133 lbs.
Review of the resident's weights and vitals summary dated 2/7/24 showed the resident weighed 133 lbs.
Review of a nutrition/dietary note dated 2/20/24 completed by the facility's RD showed the resident's weight was stable.
Review of the resident's March 2024 POS showed:
-A physician's order for a regular diet with mechanical soft texture (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool), thin liquids (un-thickened liquids like water or juice) consistency, *Per Os (PO- by mouth) feedings at the resident request* thin liquids, soft/moist, easy-chew solids.
-An order for Jevity 1.5 at 55 ml per hour by pump.
NOTE: No order was found related to the resident being weighed more frequently.
During an interview of 3/5/24 at 10:50 A.M. the resident said:
-He/She was unsure if he/she had lost any weight.
-He/She was unsure how the facility was maintaining his/her weight.
3. During an interview on 3/5/24 at 10:34 A.M. Certified Nursing Assistant (CNA) B said:
-He/She did not think Resident #8 had any weight loss.
-Resident #8 was weighed monthly.
-Therapy was in charge of weighing the residents.
-Resident #8 had not complained of losing weight.
-If any resident reported any weight loss or gain to him/her, then he/she would report it to the charge nurse.
-Therapy would let the CNAs know if the resident had lost weight or if they could not obtain the weight at that time.
-All residents were weighed once a month.
-An order would be needed for weights to be done more frequently.
-He/She was able to see weights within the residents' charts.
During an interview on 3/5/24 at 10:55 A.M. CNA C said:
-He/She did not think that Resident #10 had lost any weight.
-The RA completed the monthly weights.
-If a resident were to tell him/her that they were losing weight then he/she would weigh the resident and report the weight to the charge nurse.
-He/She was able to see weights within the residents' charts.
-Resident #10 had a recent diet change and thought the resident was now on a mechanical soft diet.
During an interview on 3/2/24 at 11:13 A.M. Licensed Practical Nurse (LPN) A said:
-All residents in the facility were weighed once a month unless there was a more specific order.
-He/She had only worked at the facility for a month, so he/she was unsure of Resident #8 or Resident #10 had lost weight.
-If a resident was losing weight there would be a detailed nurse's note related to the weight loss and weight management.
-If he/she saw more than a three-pound weight difference for any resident, then he/she would notify the physician.
-For residents with weight loss their intake and output were recorded by the nurse during the shift.
During an interview on 3/5/24 at 11:22 A.M. Registered Nurse (RN) A said:
-He/She did not know if Resident #8 had lost weight.
-He/She did not think that Resident #10 had any weight loss.
-The Assistant Director of Nursing (ADON) and Director of Nursing (DON) monitored the residents for weight loss.
-He/She was unsure if there was a weight loss alert within the facility's electronic charting system.
-The facility's RD also looked at resident weights.
-Resident #10 was currently on monthly weights.
During an interview on 3/5/24 at 11:57 A.M. the ADON said:
-He/She had noticed that Resident #8 had lost weight.
-Resident #10 had been on a trial diet of pureed food, but he/she had been placed back onto tube feeding with pleasure feeding.
-Resident #10's trial diet could have caused the resident to lose weight.
-It was the nurses responsibility to document resident intake and output.
-The RA was responsible for weighing the residents.
-The RA was responsible for telling management about weight loss.
-Resident weights were discussed monthly during the facility's Quality Assurance and Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) meeting.
-There had been an issue with the calibration of the facility's scale in the past.
-If a resident had a significant change in weight, then the resident needed to be re-weighed to ensure accuracy of the weight.
-Resident #8 and Resident #10 should have been re-weighed due to the significant difference in weight.
-If it was determined that a resident was losing weight, then he/she would inform the doctor, inform the RD, and put the weight loss and interventions on the resident's care plan.
During a phone interview on 3/7/24 at 8:33 A.M. the facility's RD said:
-He/She thought that Resident #8 and Resident #10 had weight discrepancies and not actual weight loss.
-He/She had told the facility that all residents needed to be re-weighed to get a new baseline weight for each resident due to the inconsistency in weights.
-He/She would have expected the facility to re-weigh Resident #8 and Resident #10 after noticing the significant change in weight.
-He/She remembered when Resident #10 admitted to the facility and had to remind the staff multiple times that the resident needed to be weighed.
-He/She expected the residents to be weighed monthly and was unsure why Resident #10 did not have weights documented in October or November 2023.
During a phone interview on 3/8/24 at 8:24 A.M. the facility's physician said:
-He/She had a hard time with weights in general at the facility due to the inconsistency.
-He/She thought Resident #10 had been at the hospital at the times when the facility would have done the monthly weights.
-He/She did not think that Resident #8 had lost any weight.
-Resident #10 could have lost weight while in the hospital and weight loss at that time would have been expected with the resident's current state and disease process.
-Resident #8 had been morbidly obese, so if the resident had lost weight, it would have been appropriate.
-He/She would have expected the facility the re-weigh Resident #8 and Resident #10 when there had been a significant drop in weight.
-The monthly QAPI meetings seemed to be when the facility discussed weights, but the facility's management might also be having daily Person at Risk (PAR) meetings.
-He/She would not change the treatment plan for either resident.
-When looking at resident weight loss he/she usually looked at the graph in the facility's charting system.
-If the graph showed a steep drop in weight, then he/she would not think the weight was accurate.
-He/She would discuss with management about the inconsistent weights.
MO00231857
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain physician's orders to ensure the intake of tube...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain physician's orders to ensure the intake of tube feeding and fluids was completed, failed to ensure the flush bag was dated and labeled, and failed to ensure the tube feeding bag and flush bag were changed every 24 hours, for one sampled resident (Resident #10) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube that is passed into a person through the abdominal wall, commonly used to provide a means of feeding when oral intake is not adequate) out of 10 sampled residents. The facility census was 101 residents.
Review of the facility's policy titled Enteral (passing through the intestine) Feeding via Continuous Pump dated November 2018 showed:
-In preparation staff would need to verify that there is a physician's order for this procedure.
-The person performing this procedure should record the following information:
--The date and time the procedure was performed.
--Verification of tube placement.
--Amount and type of enteral feeding.
--The average fluid intake per day.
--The name and title of the individual(s) who performed the procedure.
--All assessment data obtained during the procedure.
--How the resident tolerated the procedure.
--If the resident refused the procedure, the reason(s) why and the interventions taken.
-The signature and title of the person recording the data.
NOTE: There was no part in the policy that indicated the flush bag (bag containing water) for water boluses (used as a way for the person receiving tube feeding hydration) needed to be dated/labeled.
1. Review of Resident #10's Face Sheet showed he/she was first admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses:
-Paraplegia (paralysis of the legs and lower body).
-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses).
-Unspecified Severe Protein-Calorie Malnutrition.
-Dysphagia (difficulty or discomfort in swallowing).
Review of the resident's Physician Order Sheet (POS) dated 8/30/23 showed:
-An order for Jevity (a fiber-fortified tube feeding formula) 1.5, 55 ml per hour by pump.
-Flush PEG tube with 150 ml of water every six hours.
Review of the resident's POS dated 12/21/23 showed an order for a regular diet with mechanical soft texture (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool), thin liquids (un-thickened liquids like water or juice) consistency, *Per Os (PO- by mouth) feedings at the resident request* thin liquids, soft/moist, easy-chew solids.
Review of the resident's Care Plan dated 12/12/23 showed the resident required tube feeding related to dysphagia with an intervention to see physician's orders for current feeding orders.
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/13/23 showed:
-The resident had moderately impaired cognition.
-The resident did not have a swallowing disorder.
-The resident received 51% or more of his/her proportion of total calories needed received through a feeding tube.
-The resident received 500 cubic centimeters (cc- also equivalent to a milliter (ml)) a day or more of average fluid intake by feeding tube.
Review of the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated February 2024 showed no documentation related to the resident receiving his/her tube feeding.
Review of the resident's MAR/TAR dated March 2024 showed no documentation related to the resident receiving his/her tube feeding.
Observation on 3/4/24 at 11:03 A.M., of the resident's tube feeding showed:
-It was labeled as hung at 3/4/24 at 10:46 A.M.
-It was running at 55 ml an hour.
-The flush bag was not labeled.
Observation on 3/5/24 at 10:50 A.M., of the resident's tube feeding showed:
-It was the same bottle from the day before as it was labeled as hung on 3/4/24 at 10:46 A.M.
-It was running at 55 ml an hour.
-The flush bag was not labeled.
During an interview on 3/5/24 at 11:13 A.M., Licensed Practical Nurse (LPN) A said:
-He/She would not expect the resident's tube feeding administration to show up on the TAR because it was a continuous order.
-He/She had only worked with the resident once before and was not sure about his/her specific orders.
During an interview on 3/5/24 at 11:22 A.M., Registered Nurse (RN) A said:
-The resident's tube feeding administration should show up on the resident's MAR/TAR.
-There was a place to document the resident's water flushes on the MAR/TAR.
-The resident was on a continuous feed, so he/she knew that it needed to be hung every 24 hours.
-The resident needed a new bottle about once a day.
-He/She just monitored the tube feeding and did not need the TAR notification for the bottle to be changed out.
-The resident's flush bag did not need to be labeled because it would be changed out with the rest of the tube feeding administration tubing.
During an interview on 3/5/24 at 11:57 A.M., the Assistant Director of Nursing (ADON) said:
-Tube feeding bottles should only be hung for a maximum of 24 hours.
-He/She expected staff date and label the tube feeding bottle and flush bag.
-There should be an order in place for the resident to receive tube feeding.
-There should be a place on the TAR for the nurses to document that the resident's tube feeding was given.
-He/She was unsure why there was not a place on the TAR for the nurses to document the tube feeding.
-He/She thought that due to a recent diet change the resident's tube feeding order may have dropped from the resident's original POS and when it was re-ordered the order was not given a schedule for the TAR.
-He/She expected staff to document when tube feeding was given.
MO00231857
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
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 call light system was operable and within r...
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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 call light system was operable and within reach for one sampled resident (Resident #1), who was bedbound and needed total assistance from staff for care, out of 10 sampled residents. The facility census was 101 residents.
Review of the facility's Call light policy and procedure dated March 2021, showed:
-The purpose was to ensure timely responses to the resident's requests and needs.
-Be sure the call light is plugged in and functioning at all times.
-When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.
-Some residents may not be able to use their call light. Be sure you check these residents frequently.
1. Review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses of quadriplegia (a form of paralysis that affects all four limbs, plus the torso), stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain), diabetes, morbid obesity (weight is more than 80 to 100 pounds above their ideal body weight), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), bipolar disorder (a mental health condition that causes extreme mood swings), high blood pressure, muscle spasm, depression, asthma (a condition in which the airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe) and rapid heart rate.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/25/23, showed the resident:
-Was alert, oriented and had no cognitive incapacities.
-Had upper and lower range of motion impairment on both sides of his/her body.
-Was totally dependent on nursing staff for bed mobility, transfers, mobility, eating, bathing, dressing, toileting and did not walk or stand.
Review of the resident's Care Plan updated 2/17/24, showed the resident required maximum assistance of two to three staff for turning and bed mobility, transfers, bathing and needed the assistance of one to two staff for toileting and hygiene. It showed:
-The resident was at risk for falls and staff were to keep the resident's call light within reach and encourage the resident to use it. The resident needed prompt response to all requests for assistance.
-The care plan did not show the resident refused to use his/her call light or that he/she was unable to use a call light. There was no documentation showing the facility had an alternate method for the resident in place of call light usage.
Observation and interview on 3/4/24 at 12:00 P.M., showed the resident was in a room by himself/herself. He/She was laying in a bariatric bed, on his/her back. The resident had a tray table with a small speaker on top of it that was beside the resident's bed. There was also a cell phone on the tray table. There was no call light within the resident's reach. It was not on the floor or wedged between the resident's bed and the wall. Further observation showed that there was no call light plugged into the wall for the resident. There was a pad call light that was unplugged and sitting on another bed that was behind the resident. The resident said:
-Usually his/her call light was on the floor and was rarely within his/her reach.
-He/She was unable to move himself/herself in bed so he/she was unable to see where his/her call light was.
-Nursing staff had to place the call light within reach of his/her right hand in order for him/her to use it.
-He/She used the [NAME] (a virtual assistant technology using voice activation) speaker to call for assistance by asking it to call the facility phone and then when someone answers the telephone he would let them know he/she needs assistance.
-[NAME] rang the telephone 10 times before it hung up the telephone call.
-Sometimes he/she had to call several times when no one answered the telephone.
-At this time, the resident asked [NAME] to call the facility. The telephone called the facility telephone and the telephone rang 10 times before the call was disconnected. The resident said he/she would normally call again until someone answered.
Observation and interview on 3/4/24 at 12:11 P.M., Certified Medication Technician (CMT) A came into the resident's room and began to look for the resident's call light. CMT A said:
-He/She did not see that the resident had a call light and was not able to find it.
-The resident usually called the facility using [NAME] to request assistance, but he/she should not have to call on the telephone line to notify someone that he/she needed help.
-The resident should have his call light available to use in addition to [NAME].
-The current call light system functions this way: the resident will push the call light and information showing the date, room and time the call light was pushed will display on the monitor at the nursing station.
-There was no longer a light that came on over the resident's door that notified staff that the call light was on and there was no sound to identify a call light was on anymore.
-Nursing staff had to go to the nursing station to know if someone had turned their call light on now.
Observation and interview on 3/4/24 at 12:28 P.M., Certified Nursing Assistant (CNA) A came into the resident's room and began to look for the resident's call light. CNA A saw the pad call light on the bed behind the resident, picked it up and sanitized it, then plugged it into the wall and placed it beside the resident's right arm. CNA A said:
-The resident did not really use his/her call light and rather used the [NAME] to call the facility for assistance.
-He/She did not know why the resident's call light was not plugged in or available for the resident.
-The resident was not able to move in bed without assistance and had limited mobility in his/her arm.
-He/She usually checked on the resident more frequently during the day and anticipated his/her needs.
Observation on 3/4/24 at 12:30 P.M., showed when CNA A left the resident's room, the resident used his/her right hand to push the pad alarm, which showed that it was on at the wall (plug in) in his/her room. Observation at the nursing station showed there was a monitor at the nursing station that showed the resident had turned his/her call light on and showed the date, room number and time the call light was turned on.
During an interview on 3/5/24 at 10:39 A.M., Registered Nurse (RN) A said:
-The resident had limited movement in his/her hands and arms which is why he/she did not use a call light.
-The resident had a pad call light because he/she was unable to use the standard call light, but he/she did not use it either and would throw it on the floor.
-The resident preferred to use [NAME] to call the staff when he/she needed assistance.
-The [NAME] called the facility and the call rang in the front administrative area as well as at the nursing stations.
-This was his/her only means of letting them know when he/she needed assistance.
-The resident called several times daily for assistance.
-If there was no one at the nursing station or in the offices, then the resident would have to wait until someone got to the telephone to answer it to find out that he needed assistance.
-The call light system was their standard system for notifying staff that a resident needed assistance.
-The resident's call light should be plugged in and available for the resident to use if he/she chose to use it.
-Their new current call light system did not sound or light up above the resident's door when the call light was activated. The nursing staff would have to check the monitor at the nursing station to know if a call light was on.
-The nursing aides should check the monitor at the nursing station frequently to see if there were call lights activated. If they answer a call light, when they are done assisting a resident they are expected to check the monitor to see if there were other call lights activated.
During an interview on 3/5/24 at 11:00 A.M., the Administrator said:
-They are implementing a new call light system and when the resident activates the call light, the monitor at the nursing station will display the date, room, time the call light was activated and how long it had been on.
-There was a beeping sound that is also activated at the nursing station when a call light has been activated and it will stop when the call light has been answered.
-The sound can be also be deactivated at the nursing station if someone turned the sound off.
-The pagers (like a cell phone) that are paired to the call light system will also activate when a call light is activated. The nursing staff are going to have the cell phones so they will know when the call light is activated and the pagers will tell them where the light is activated.
-The staff will also be able to use the pagers like a cell phone to communicate with each other.
-He/She had not yet distributed the pagers so this part of the call light system was not yet operating-he/she was going to do this with training within the week.
-In the meantime, he/she expected staff to check on the residents frequently and check the monitors frequently. The sound on the monitor should not be turned off.
-Regarding the resident, he/she used [NAME] to call the facility to notify them is he/she needed assistance, however his/her call light should have been plugged up and within his/her reach.
-The resident was able to use his/her right arm to activate the pad and they obtained the pad call light specially for him/her for this reason.
-Nursing staff should be checking the resident more frequently, which was why they placed him/her closer to the nursing station.
During an interview on 3/5/24 at 3:00 P.M., the Assistant Director of Nursing (ADON) said:
-He/She expected resident call lights to be plugged in and accessible to the resident at all times.
-Nursing staff should check on the residents every two hours and they should be checking to ensure call lights are available and within reach.
-The new call light system they are using does not have lights that identify which rooms have call lights activated or a sound that is audible.
-The monitor at the nursing station was how the nursing staff know there was a call light on and the expectation was that nursing staff was checking the monitor frequently to know whether a call light had been activated.
-The resident had been using his/her [NAME] to call the facility to let them know he/she needs assistance, but this was not the protocol for the facility.
-They ordered a pad alarm for the resident to use because he/she was unable to use the standard call light, but the resident chose to use [NAME].
-The call light should be accessible to the resident whether he/she used [NAME] or not.
MO00231895
MO00232373
Aug 2023
4 deficiencies
4 IJ (2 facility-wide)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision for one sampled resident (Resident #614) who wa...
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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 supervision for one sampled resident (Resident #614) who was identified at risk on the facility's elopement risk assessment and was actively exit-seeking prior to the elopement . On 8/17/23 the resident broke out a facility window and walked to a busy street. Licensed Practical Nurse (LPN) A saw the resident on the street, returned to the facility without the resident and reported where he/she last saw the resident. The Administrator was notified and the resident was found three blocks away from the facility out of 37 sampled residents. The census was 110 residents.
On 8/24/23 at 10:15 A.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 8/17/23. On 8/17/23 the facility administration was notified of the incident and the investigation was started. No employees were allowed to work prior to reeducation. The IJ was corrected on 8/19/23.
Review of the facility's undated Wandering and Elopement policy showed:
-If identified as at risk for wandering, elopement or other safety issues, the resident's care plan should include strategies and interventions to maintain the resident's safety.
-If an employee observed a resident trying to leave the premises, he/she should attempt to prevent the resident from leaving, in a courteous manner; he/she should get help from other staff members in the immediate vicinity, if necessary; and should instruct another staff member to inform the charge nurse or director of nursing services (DON) that a resident was attempting or had left the premises.
-If a resident was missing, the elopement emergency procedure should be initiated, which was to determine if the resident was out on an authorized leave or pass; notifying the administrator and DON, the resident's legal representative, the attending physician, and law enforcement officials, if necessary.
-When the resident returned to the facility, the DON or the charge nurse should examine the resident for injuries; contact the attending physician and report findings and condition of the resident; the resident's legal representative should be notified; an incident report should be completed and filed; and relevant information documented in the resident's medical record.
1. Review of Resident #614's facesheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Unspecified psychosis not due to a substance or known physiological condition (a mental disorder characterized by disconnection from reality).
-Dementia in other diseases classified elsewhere, unspecified severity, (a group of conditions characterized by impairment of at least two brain functions), with psychotic disturbance, (a collection of symptoms that affected the mind, where there was loss of contact with reality).
-Unspecified dementia, with agitation, (a state of inner tension and restlessness).
-Major depressive disorder, (a mood disorder that produced a persistent feeling of sadness and loss of interest).
-Family Member A was the resident responsible party.
Review of the resident's hospital medical record, dated 5/31/23, showed he/she needed memory care placement and was an elopement risk.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 6/14/23, showed:
-The resident exhibited behaviors and wandering that had worsened from prior assessment.
-He/she had a Brief Interview for Mental Status (BIMS) score of 6 indicating he/she was cognitively impaired.
Review of the resident's facility Wandering Risk Scale, dated 7/20/23, showed he/she had a score of 10, which placed him/her in the category of at risk to wander.
Review of the resident's progress note, dated 8/17/23 at 4:48 P.M., showed:
-He/she broke the window in his/her room, and crawled out the window and began walking down the street towards a busy street.
-He/she was observed by staff who was arriving to the facility.
-The facility Administrator and the DON were immediately notified.
-He/she was located by the facility Administrator.
-He/she was returned to the facility by the police.
-He/she was initially unwilling to enter the facility.
-He/she was accompanied willingly into facility with staff.
-He/she was assessed and negative for injury, cuts, or bruising.
-Physician A was notified by phone with no new orders received.
-Family member was notified via phone.
Review of the resident's progress note, dated 8/18/23 at 11:04 A.M., showed:
-It was reported by another resident that he/she attempted to exit the facility front door three times by pushing on it to open.
-The attempts were unsuccessful.
-He/she remained with close protective oversight by staff.
Review of the facility's Suspected Abuse Investigation, dated 8/18/23 at 2:00 P.M., showed:
-The resident attempted to exit the facility out the front door on the morning of 8/17/23.
-After being redirected, he/she went to his/her room and relaxed.
-Shortly after lunch, the resident returned to his/her room and physically broke the security lock in order to open the window beyond six inches.
-He/she opened the window and removed the screen.
-He/she stepped out the window and began to walk around the facility.
-He/she was first acknowledge by staff a block away from the facility, but failed to get the resident to return.
-The resident began to have behaviors, so the Licensed Practical Nurse (LPN) returned to the facility for his/her safety.
-The LPN notified the Administrator who immediately began to search for the resident in his/her car.
-The Administrator called the DON and notified him/her that he/she had begun to search for the resident.
-The resident was located three blocks from the facility.
-The administrator tried to convince the resident to return, due to the temperature outside, but the resident stated he/she was ok.
-The Administrator followed the resident and continued trying to convince him/her to return, but also called the police for assistance.
-The resident became agitated and started striking the Administrator.
-The resident said he/she was going to run into the traffic and darted toward the street.
-The Administrator wrapped his/her arms around the resident's waist, holding him/her in order to prevent serious injury.
-The police arrived and the resident calmed down.
-The resident agreed to return to the facility with the police officers.
-The resident was physically assessed by the DON and found to have no injuries or physical distress.
-The facility initiated finding placement for the resident at a facility with a locked unit.
-The staff member who initially discovered the resident should not have let him/her leave his/her sight and called for assistance instead.
During an interview on 8/21/23 at 9:15 A.M., Maintenance Director A said:
-The security locks were put on the windows with a special tool that snapped them on.
-The resident did not say how he/she got the lock off.
-All of the other resident windows were fitted with the same locks, which would prevent the windows from sliding open more than approximately six inches.
-There had not been any previous issues with residents removing locks.
-He/she walked the building three times a week to check the security locks.
-He/she did not really know this resident well, because he/she usually kept to him/herself or walked around the facility.
During an interview on 8/21/23 at 10:30 A.M., the resident's family member A said:
-He/she was the resident's power of attorney.
-He/she was aware of the resident eloping.
-The resident had tried to leave two previous facilities.
-The whole reason the resident was transferred to this facility was because the facility administration had assured the resident could be properly cared for.
-He/she had reported to the front desk receptionist the resident could not be let out and the resident would try and escape.
-He/she told the social worker the resident tried to leave two previous facilities when paperwork was completed for the resident.
During an interview on 8/21/23 at 10:40 A.M., the resident said:
-He/she wanted to walk around the neighborhood and see his/her godfather's old house and look at the churches.
-He/she did not remember leaving the facility.
During an interview on 8/21/23 at 10:57 A.M., LPN A said:
-He/she had only worked at the facility a few weeks, and did not know all the residents' names to their faces.
-He/she had been on his/her lunch break, around 1:00 P.M., on 8/17/23 and was coming back from a restaurant.
-He/she saw the resident at the four-way stop on a street near the facility Avenue.
-The resident was wearing a plaid shirt, pants, and shoes.
-The resident was walking along, and he/she did not know if the resident was was on the list of people who should not leave the facility without permission.
-He/she stayed in his/her car and lowered the window and asked the resident where he/she was going.
-He/she could not make out the resident's answer.
-He/she had heard this resident could be combative, so he/she was not sure if he/she should approach him/her any further.
-Since he/she did not know if the resident was supposed to be out of the facility, he/she felt it would be faster to go to the facility and tell someone, rather than call the facility from his/her car.
-When he/she got to the facility, Registered Nurse (RN) A, with whom he/she had been training, was also eating lunch in the parking lot, and he/she asked him/her if the resident should be out.
-RN A said the resident should not be out.
-He/she walked in the building and told the Administrator about it.
-He/she did not fill out an incident report.
-In retrospect, he/she thought he/she should have called the facility by cellphone and stayed with the resident.
-He/she had not had any training at the facility about resident elopement until after this happened.
During an interview on 8/21/23 at 11:20 A.M., RN A said:
-He/she had been training LPN A and was the nurse for the resident.
-LPN A was driving back to the facility and saw the resident on the street.
-He/she was eating lunch in his/her truck and LPN A told him/her that the resident was walking down the street.
-He/she told LPN A to go tell the Administrator, because the resident was not supposed to go out alone.
-He/she did not see the resident go out and continued his/her lunch.
-The Administrator went and got the resident, which only took a short time.
-The resident had been refusing his/her medications and the physician was aware.
-Prior to this incident, the resident had been acting normally.
-The staff had no idea the resident would try to exit, as he/she had never tried it before.
-Residents were supposed to be checked every two hours, but he/she had not had any more frequent monitoring previously.
During an interview on 8/21/23 at 11:30 A.M., LPN B said:
-He/she was working on the east side nursing station at the facility the morning of the elopement.
-The resident lived on the west side of the facility.
-On the morning of 8/17/23, the receptionist told him/her that the resident was trying to get out the front door.
-He/she went to redirect the resident.
-The resident said he/she had to go to his/her house in Independence, which he/she thought was in walking distance, to get some paperwork.
-He/she took the resident to the facility's courtyard to redirect him/her.
-The resident told him/her, This is a joke and you know it! and waved his/her hand dismissively.
-When the resident realized he/she could not exit the courtyard, he/she wanted to go back in the facility.
-He/she reported the resident's behavior to RN A.
-RN A said the resident had not been taking his/her medications.
-After he/she talked to RN A, he/she went back to work on his/her side of the facility.
-He/she did not fill out an incident report.
During an interview on 8/21/23 at 11:55 A.M., Physician A said:
-He/she was aware of the resident's elopement, but did not know the story behind it.
-The resident was typically pretty complacent and happy where he/she was, but in the last week had been wound up.
-Usually when he/she saw the resident, he/she was just hanging out.
-He/she was aware the resident had been refusing his/her medications.
-He/she was not sure whether the medications the resident refused would have made a difference or prevented the elopement.
-Common sense would say that LPN A should have stayed with the resident.
-He/she had been unaware of the resident making any elopement attempts at other facilities, however in reviewing resident paperwork, the resident had an elopement at a previous facility, which he/she had not been aware of.
-It was obvious the resident was going to need a locked unit.
During an interview on 8/21/23 at 12:25 P.M., the Administrator said:
-LPN A came in the facility and found him/her, approximately around 1:00 P.M.
-LPN A said he/she thought he/she saw the resident out on the street.
-LPN A tried to talk to the resident and he/she refused to respond.
-He/she immediately got in his/her car, called the DON, and went to find the resident.
-He/she tried to talk the resident into coming back to the facility with him/her, and the resident started screaming that he/she was going to store.
-He/she told the resident that it was warm out and the resident said he/she was fine.
-The resident tried to hit him/her and run out into the street, so he/she put his/her arms around the resident's waist to keep him/her from doing that. He/she only did this to keep the resident from running in to traffic.
-As soon as he/she found out the resident had gotten out, he/she also notified the police.
-The police arrived and the resident calmed down and was willing to go with him/her back to the facility.
-The police tried to get the resident to go with him/her first. They just dropped him/her off at the facility and did not create a report.
-There was a list of residents who were not allowed to leave the facility and were elopement risks, and copies of it were at the nurses' stations and at the receptionist's desk.
-The person at the front desk monitored who went in and out.
-The residents' room windows were set with a lock so they could only open about six inches.
-The resident broke the lock off on his/her window and pushed the screen out to leave.
-It was his/her expectation that staff should know who was on the list of people who were elopement risks.
-It was not a good idea for LPN A to leave the resident on the street.
-He/she should have called the facility to notify of the elopement.
-For the resident's safety, he/she should have stayed with him/her.
-The resident was back at the facility around 1:30 P.M.
-The police talked to the resident for about ten minutes and then he/she came back to the facility.
-The DON assessed the resident upon his/her return, and he/she had no harm.
-He/She was aware the resident had behaviors at other facilities, but did not know if he/she had elopements.
-The resident was usually pretty calm, sometimes he/she was very clear and other times confused.
During an interview on 8/21/23 at 12:45 P.M., the DON said:
-He/She was in the facility when the resident eloped.
-Before the resident eloped, the receptionist told LPN B he/she was trying to get out the front door, and he/she tried to redirect him/her.
-Around 1:00 P.M., LPN A saw the resident on the street.
-He/she did not stay with the resident, and the resident refused to come with him/her.
-LPN A told RN A, who was also at lunch, about the resident being out, and RN A told him/her to go tell the Administrator.
-The Administrator got in his/her car and went to get the resident, who refused to come with him/her.
-The Administrator called him/her at 1:58 P.M. on 8/17/23 to see if the resident was in the building, and at 2:07 P.M., the Administrator was already with the resident.
-The Administrator then called the police, and the resident did go with the police back to the facility.
-He/she did his physical assessment when he/she returned to the facility.
-The resident was placed on 1:1 observation after that.
-He/she thought the resident might have been out an hour, though nobody knew when he/she went out.
-The resident was very smart and strong enough to break a window lock.
-It was his/her expectation that all staff should know who was on the elopement list.
-He/she thought the resident's elopement risk was low, because although he/she had made comments about leaving, he/she had never previously attempted it.
-LPN A should have called and not left the resident alone. LPN A should have kept the resident in the line of eyesight.
-He/she expected all staff once aware the resident had eloped to respond and ensure the safety of the resident.
During an interview on 8/21/23 at 3:05 P.M., Receptionist A said:
-He/she did not see the resident try to get out the door, but he/she was very adamant all morning that he/she wanted to leave.
-He/she told LPN B, because he/she was the closest to the reception desk.
-The receptionist knew he/she was not to go out the door.
-He/she notified LPN B that the resident was adamant about leaving.
-The resident told him/her he/she did not live far away and wanted to go to his/her house.
-He/she had never seen the resident behave like this before, and tried to redirect him/her.
-LPN B told the resident if he/she wanted to leave, he/she had to call his/her sister. He/she redirected him/her back to his/her room.
During an interview on 8/21/23 at 3:21 P.M., RN A said:
-The resident said he/she wanted to leave all the time.
-He/she was orienting LPN A, but was unaware if he/she knew about the elopement list.
-When LPN B brought the resident in, he/she went back to his/her room.
-The resident would often wander around the hallways.
-He/she had not given LPN B any training about what to do in an elopement situation.
-When LPN A told him/her about the resident being on the street, he/she was eating lunch and stayed in his/her truck and did not leave the parking lot.
-He/she saw LPN A run in the facility and get the Administrator and saw the Administrator run out to his/her car.
During an interview on 8/21/23 at 3:25 P.M., the Admissions Coordinator said:
-He/she did not review resident referrals.
-He/she did not know if the resident was an elopement risk.
During an interview on 8/24/23 at 11:40 A.M., the Admissions Coordinator said:
-He/she would get a referral for a resident, then it would be sent to the clinical coordinator for review and to the business office to verify benefits.
-They would make the decision whether or not to admit a resident.
During an interview on 8/24/23 at 11:45 A.M., the MDS Coordinator said:
-The nurses on the floor did the admission assessments.
-He/she would read through everything and make the care plans.
-He/she reviewed the facility's doctor's notes to create a care plan, rather than discharge notes, because with a dementia resident, the change of environment could change the resident's care plan needs.
-The facility did not get information from previous facilities about residents.
During an interview on 8/24/23 at 3:25 P.M., CNA D said:
-The resident often would wander around the unit.
-The staff would have to follow him/her around.
During an interview on 8/24/23 at 7:15 P.M., the Security Director said:
-The resident walked around the facility a lot.
-He/she had never seen the resident actively exit-seek.
-The resident could be aggressive.
-If a resident tried to exit through the front door, he/she could be stopped.
-Any resident who left through the front door had to sign out in a book.
-Staff should know who was on the elopement list.
During an interview on 8/30/23 at 1:52 P.M., the DON said:
-In an elopement attempt, staff should not lose eyesight of the resident.
-He/she and the Administrator should be contacted by phone.
-There was an elopement book at each nurses' desk and at the front desk.
-The resident should remain in constant line of eyesight until help arrived.
During an interview on 8/30/23 at 2:11 P.M., the Administrator said:
-If a staff person found a resident who had eloped, he/she should keep the the resident within eye sight.
-If the resident were aggressive, he/she should keep a distance for safety, but the resident still kept in eye sight.
-The staff person should have stayed with the resident and called for assistance.
-Staff were shown the elopement books at the time of hire.
MO00223154
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential ...
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Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus SARS-CoV-2) and other infections when staff failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to separate six sampled residents (Resident #604, #605, #606, #607, #608 and #88) who tested positive for COVID-19 from six sampled residents (Resident #609, #610, #611, #612, #613 and #504), who had tested negative for COVID-19. One sampled resident (Resident #609) turned COVID-19 positive on 8/22/23 after sharing a room with a COVID-19 positive resident (Resident #604) who was diagnosed with COVID-19 on 8/18/23, out of sample of 37 sampled residents. The facility census was 110 residents.
The Administrator was notified on 8/24/23 at 10:15 A.M., of the Immediate Jeopardy (IJ) which began on 8/18/23. The IJ was removed on 8/22/23, as confirmed by surveyor onsite verification.
Review of reference from the Center for Disease Control and Prevention (CDC), updated 5/8/23, showed:
-The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency.
-Section two: recommended Infection Prevention and Control Practices when caring for resident with suspected or confirmed SARS-CoV-2 infection showed: These residents should not be cohorted with residents who were confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing.
-Placement of the resident with suspected or confirmed SARS-CoV-2 infection in a single person room. The door should be kept closed and ideally the resident should have a dedicated bathroom.
-Section under nursing homes showed: ideally the resident should be placed in a single-person room.
-If limited single rooms are available, or if numerous resident are simultaneously identified to have SARS-CoV-2 exposure or symptoms concerning for COVID-19, resident should remain in their locations.
Review of the facility Infection Control Interim Policy related to Human Corona Virus, revision on 3/16/21, showed:
-Cohorting resident on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected resident. If cohorting symptomatic residents, care should be taken to ensure infection prevention and control intervention are in place to decrease the risk of cross-transmission.
-Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if all possible should not share rooms with other residents unless they remain asymptomatic and/or have tested negative.
1. Review of Resident #604's Face Sheet showed he/she was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).
Review of the resident's Nursing Note, dated 8/18/23 at 3:08 P.M., showed:
-Resident tested positive for COVID-19, vital signs taken and oxygen saturation levels (the amount of oxygen carried by red blood cells) was at 92% (The normal oxygen saturation level is from 97% to 100%).
-Had complaints of cough, congestion, runny nose and body aches pains.
-The resident was dependent with cares and will remain on isolation precaution for COVID-19. Resident's physician was notified of positive COVID test and symptoms.
Observation on 8/21/23 at 3:09 P.M. to 3:26 P.M., of the resident showed:
-The resident was in his/her room and shared a room with COVID negative Resident #609.
2. Review of Resident #605's Face Sheet showed he/she was admitted to the facility with a diagnosis of stroke affecting left side.
Review of the resident's Nursing Note, dated 8/20/23 at 10:26 A.M., showed:
-Resident tested positive for COVID-19.
-The resident was informed to stay in his/her room.
-The resident's physician was notified of positive COVID test and management notified.
-Nursing staff will continue to monitor the resident for any change of condition.
Observation on 8/21/23 at 3:09 P.M. to 3:26 P.M., of the resident showed:
-The resident was in his/her room and shared a room with Resident #610 who was covid negative.
3. Review of Resident #606's Face Sheet showed he/she was admitted to the facility with a diagnosis of moderate intellectual disabilities.
Review of the resident's Nursing Note, dated 8/20/23 at 10:20 A.M., showed:
-Resident tested positive for COVID-19.
-The resident was informed to stay in his/her room.
Observation on 8/21/23 at 3:09 P.M. of the resident showed:
-The resident was in his/her shared room with his/her COVID negative roommate Resident #611.
-He/She shared a private bathroom with COVID negative roommate, Resident #611.
4. Review of Resident #607's Face Sheet showed he/she was admitted to the facility with a diagnosis of dementia.
Review of the resident's Nursing Note, dated 8/20/23 at 4:00 P.M., showed:
-Resident tested positive for COVID-19.
-The resident was informed to stay in his/her room.
-Nursing staff will continue to monitor the resident for any change of condition.
Review of the resident's Nursing Note dated 8/21/23 at 3:49 P.M., showed:
-The resident refuses to wear a mask or stay in his/her room.
-The resident was COVID positive and wanted to use the telephone and for staff to give to him/her. The resident has nasal congestion. No cough noted.
-The resident went out to smoke with others and said he/she was not sick.
-The resident educated on importance of not spreading the disease, but not effective.
Observation on 8/21/23 at 3:12 P.M., the resident showed:
-The isolation (ISO) room door was open and the resident had just exited out of the shared bathroom.
-The resident privacy curtain was not pulled and did not have a mask on at that time.
-Roommate Resident #612 (who COVID-19 negative) was also in room and did not have mask on.
5. Review of Resident #608's Face Sheet showed he/she was admitted to the facility with the following diagnoses of:
-Cancer of the bladder.
-admitted to hospice (end of life) services.
Review of the resident's Nursing Note, dated 8/20/23 at 10:17 A.M., showed:
-Resident tested positive for COVID-19.
Observation on 8/21/23 at 3:09 P.M., of the resident showed:
-The resident was in his/her room with his/her Covid negative roommate, Resident #613.
Review of the resident's Nursing Note, dated 8/22/23 at 12:42 A.M., showed:
-The resident being monitored due to having COVID-19.
-Vital signs taken and had a temperature of 99.1 degrees Fahrenheit (° F) (The average normal temperature is 98.6°F).
-The resident had no complaints at that time.
6. Review of Resident #88's Face Sheet showed he/she was admitted to the facility with the following diagnoses of Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception).
Review of the resident's COVID-19 testing verification dated 8/21/23, no time when tested showed the resident tested positive for COVID.
Review of the resident's Nursing Note, dated 8/21/23 at 5:34 P.M., showed:
-The resident was not feeling well and went to nurse with complaints of dizziness and not feeling well in general with a low grade temperature of 99°F and oxygen saturation levels at 93%.
-The resident tested positive for COVID-19.
During an interview on 8/22/23 at 10:32 A.M., Director of Nursing (DON) said:
-Resident #88 tested positive for COVID-19 on 8/21/23.
-Resident #88 did have a roommate, Resident #511 who tested negative for COVID on 8/21/23.
7. Review of Resident #609's Face Sheet showed he/she was admitted to the facility with the following diagnoses:
-Dementia.
-Type 2 Diabetes Mellitus with hyperglycemia (happens when the body has too little insulin or when the body can't use insulin properly, with high blood sugars).
Review of the resident's COVID-19 testing verification dated 8/18/23, no time when tested, showed the resident tested negative for COVID.
Review of the resident's roommate, Resident #604 showed he/she had tested positive on 8/18/23.
Observation on 8/21/23 at 9:35 A.M., of the resident's room showed:
-The resident was in his/her room in isolation with COVID positive roommate, Resident #604.
-Did not have face mask on and privacy curtain (to be used as barrier) was not pulled.
Review of the resident's Nursing Note, dated 8/21/23 at 1:40 P.M., showed:
The resident refused to stay in his/her room.
-The staff educated the resident on importance of not spreading disease, his/her roommate had COVID-19.
-The resident kept getting out of his/her room and propelling himself/herself wherever he/she wanted to go in the facility.
-The resident said he/she does not care and he/she was not sick.
Review of the resident's COVID-19 testing verification, dated 8/22/23, no time when tested, showed the resident tested positive for COVID.
During an interview on 8/22/23 at 10:32 A.M., DON said:
-The facility had two additional residents test COVID-19 positive.
-Resident #609 tested positive for COVID-19 on 8/22/23.
-He/she was roommate to Resident #604 who tested positive on 8/18/23 and had been cohorting with negative resident.
8. Review of Resident #610's Face Sheet showed he/she was admitted to the facility with the following diagnoses of:
-Multiple Sclerosis (MS, is a potentially disabling disease of the brain and spinal cord (central nervous system).
-History of COVID-19.
-Dementia.
Review of the resident's COVID-19 testing verification, dated 8/20/23, no time when tested, showed the resident tested negative for COVID.
Review of the resident's Nursing Notes for 8/1/23 to 8/22/23 showed the resident had no documentation that he/she was placed in isolation due to his/her roommate Resident #605, had tested positive for COVID-19 on 8/20/23.
Review of the resident's Physician Order Sheet (POS) and TAR from 8/1/23 to 8/31/23 showed no physician order documented for monitoring for signs and symptoms or for testing the resident for COVID-19.
Observation on 8/21/23 at 9:35 A.M., of the resident's room showed:
-The resident was in isolation with covid positive roommate, Resident #605.
9. Review of Resident #611's Face Sheet showed he/she was admitted to the facility with the following diagnoses of:
-Past history of COVID-19 on 8/11/22.
-Cancer of the breast.
-Dementia.
Review of the resident's roommate Resident #606, showed he/she had tested positive on 8/20/23.
Review of the resident's COVID-19 testing verification dated 8/20/23, no time when tested showed the resident tested negative for COVID.
Review of the resident's Nursing Notes, dated 8/1/23 to 8/22/23, showed the resident had no documentation that Resident #611 was placed in isolation due to his/her roommate Resident #606, had tested positive for COVID-19 on 8/20/23.
Review of the resident's POS and TAR, dated 8/1/23 to 8/31/23, showed no physician order documented for monitoring for signs and symptoms COVID-19 or for testing the resident for COVID-19.
Observation on 8/21/23 at 9:37 A.M., of the resident's room showed:
-The resident was in his/her room with his/her positive roommate, Resident #611.
-The resident did not have face mask on while in room.
10. Review of Resident #612's Face Sheet showed he/she was admitted to the facility with a diagnosis of Diabetes Mellitus.
Review of the resident's COVID-19 testing verification dated 8/20/23, no time when tested showed the resident tested negative for COVID.
Review of the resident's roommate, Resident #607 showed he/she had tested positive on 8/20/23.
Review of the resident's Nursing Notes , dated 8/1/23 to 8/22/23, showed the resident had no documentation that Resident #612 was placed in isolation due to roommate, Resident #607 had tested positive for COVID-19 on 8/20/23.
Review of the resident's POS and TAR from 8/1/23 to 8/31/23 showed no physician order documented for monitoring for signs and symptoms COVID-19 or for testing the resident for COVID-19.
Observation on 8/21/23 at 9:37 A.M., of the resident's room showed:
-The resident was in his/her room with positive roommate, Resident #607.
-Privacy curtain not pulled.
-The resident did not have mask on while in room.
-The resident positive roommate, Resident #607 was up ambulating in their room.
11. Review of Resident #613's Face Sheet showed he/she was admitted to the facility with the following diagnoses of:
-Dementia.
-Chronic kidney disease.
Review of the resident's COVID-19 testing verification, dated 8/20/23, no time when tested showed the resident tested negative for COVID.
Review of the resident's roommate Resident #608 showed he/she had tested positive for COVID on 8/20/23.
Review of the resident's Nursing Notes for 8/1/23 to 8/22/23 showed the resident had no documentation that Resident #613 was placed in isolation due to roommate, Resident #608, tested positive for COVID-19 on 8/20/23.
Review of the resident's TAR dated 8/1/23 to 8/31/23 showed:
-May perform COVID-19 testing as needed for development of COVID-19 symptoms, routine screening or facility outbreak ordered on 1/17/23.
-Had no documentation of the resident COVID-19 testing for that month.
Observation on 8/21/23 at 9:37 A.M., of the resident's room showed:
-The resident was in his/her room with positive roommate,Resident #608.
-Privacy curtain not pulled.
-The resident did not have mask on while in room.
12. Review of Resident #504's Face Sheet showed he/she was admitted to the facility with a diagnosis of Chronic Kidney Disease.
Review of the resident's COVID-19 testing verification dated 8/15/23, no time when tested showed the resident tested negative for COVID.
Review of the resident's Nursing Notes, dated 8/1/23 to 8/22/23, showed the resident had no documentation that Resident #504 was placed in isolation due to roommate, Resident #88 tested positive for COVID-19 on 8/21/23.
Review of the resident's TAR dated 8/1/23 to 8/31/23 showed:
-May perform COVID-19 testing as needed for development of COVID-19 symptoms, routine screening or facility outbreak ordered on 3/20/23.
-Had no documentation of the resident COVID-19 testing for that month.
Observation on 8/22/23 at 10:55 A.M., of the resident showed:
-He/she was at doorway of room and did not have a mask on.
-Certified Nursing Assistant (CNA) communicated with the resident and a COVID negative resident, Resident #511 who resided in the room next door to Resident #504.
During an interview on 8/22/23 at 10:55 A.M., RN B said he/she was prepping to COVID test all residents in the building.
13. Review of facility email sent on 8/16/23 to City Health Department showed:
-The facility had four positive residents with COVID, who had tested positive on 8/15/23. All residents have been tested, the total census was 108 residents.
-The facility had 3.7% of their residents test positive for COVID.
-In a 10-day time frame, six facility employees have tested positive for COVID out of 105 employees, which would be 5.7% of employees who have tested positive for COVID.
-The facility plan put in place for ongoing COVID testing of the building and staff on Friday 8/18/23 and again on Sunday 8/20/23 per the CDC guidelines.
During an interview on 8/21/23 at 9:30 A.M., the Administrator, DON, and Assistant Director of Nursing (ADON) said:
-The facility currently had five residents who were COVID positive.
-The facility did not have an ISO unit and did not dedicate any rooms for those COVID positive residents.
-The facility did not have the extra room to be able to isolate negative residents from positive residents.
-The facility was following the Centers for Medicare and Medicaid Services (CMS) Reference QSO-23-13-ALL dated 5/1/23 showed Guidance for expiration of the COVID-19 Public Health Emergency related to cohorting already exposed residents.
Observation on 8/21/23 at 9:35 A.M., of the facility isolation residents rooms showed:
-Residents that were in isolation room in their rooms due to testing positive for COIVD were Resident #607, Resident #608, Resident #606, Resident #605, and Resident #604.
-A few of the residents' doors were open.
-The facility had positive resident and negative roommate cohorting in same room. Isolation in place.
-The COVID isolation room did not have privacy curtains pulled as a infection control barrier and neither resident wore mask while in room together.
During an interview on 8/21/23 at 10:30 A.M., Registered Nurse (RN) A and Certified Medication Technician (CMT) A said:
-Resident #604, Resident #605, Resident #606, Resident #607 and Resident #608 were all COVID-19 positive.
-Those residents' roommates (Resident #609, Resident #610, Resident #611, Resident #612 and Resident #613) tested negative at that time.
-The facility had just tested all residents and staff for COVID-19 on 8/20/23.
-RN A said they were to monitor the COVID-19 positive resident and their roommates for signs and symptoms for COVID-19.
-The COVID positive residents and COVID negative roommates were to isolate in their room with the door closed, privacy curtain pulled, and encourage use of masks when in contact with roommate.
During an interview on 8/21/23 at 10:40 A.M., DON said:
-The first COVID-19 positive resident was on 8/15/23. That resident was sent to the hospital on 8/18/23.
-The facility completed COVID-19 testing for all residents on 8/20/23.
-The CDC guidance reference showed the residents were to be on ISO for three days if already exposed and to maintain those resident in one location.
-The positive resident and the negative roommate could isolate together in the same room since they were already exposed to COVID-19 by the roommate.
-The Infection Control Preventionist (ICP) had sent an email to notify the city health department of positive COVID-19 residents
During an interview on 8/21/23 at 11:55 A.M., Physician A said:
-The expectation would be that the facility would follow the current CDC guidance on room placement for residents who were positive for COVID-19.
-The COVID-19 positive residents should be in isolation for a period of at least 5 days.
-Most of the COVID positive residents were asymptomatic.
-For a roommate who tested negative, the guidelines were the wild, wild west (unclear).
-The facility tried to isolate the COVID-19 positive residents the best they could.
-He/she spoke with Physician B, who was an infectious disease specialist at a hospital out of the area, who said the best thing would be to cohort the COVID-19 positive residents together, but if facility could not find separate isolation rooms, they should do the best they could with isolation in place.
-Non-symptomatic residents were probably not contagious at that time.
During an interview on 8/21/23 at 12:00 P.M., DON said:
-He/she had just talked with County Health Department related to cohorting positive roommates with negative residents.
-Was informed that since the roommate had already been exposed, the facility did not need to separate positive and negative roommates.
-Recommended isolate in room for five days and to wear a mask for 10 days after isolation.
Review of the documentation of conversation with DON and a local County Health Department representative, dated 8/21/23 and untimed, showed:
-Related to positive COVID residents in long term care facility with shared semi-private rooms.
-The recommendation for semi-private rooms when one resident tested positive and one does not, but is exposed: the residents can stay in the same room together.
-Isolation in room for five days and the resident who tested positive should be encourage to wear mask for 5 more days once off isolation.
-While in a semi-private room, the resident privacy curtain can be used as a barrier and plastic placed on entrance into the resident room.
-Isolation carts should be located at each room that has a COVID-19 positive resident.
-Signed by the DON on 8/21/23.
During an interview on 8/21/23 at 12:40 P.M., County Health Department said:
-The facility did call the county and did inform the facility need to contact the city health department for additional guidance and for reporting of any COVID-19 infections.
-He/she did inform the facility, that County Health department was made aware of an other long term care facility who had limtied space, was approved to cohorted roommates together after one resident had tested positive for COVID-19 and the roommate was COVID negative.
-Since roommate already exposed would isolate in place for 5 days and the facility uses barriers in room to separate the resident, such as privacy curtain, and encourage the resident to wear masks when in room together.
-The facility should be testing the negative roommate two days after exposure of COVID-19 and then follow the recommendation for testing for COVID-19 every 48 hours.
During an interview on 8/21/23 at 1:35 P.M., Infection Control Preventionist (ICP) said:
-He/she had reported the first positive cases to City Health Department on 8/16/23 after they completed facility COVID testing for resident and staff on 8/15/23.
-He/she was not aware of any resident who were immunocompromised.
-He/she was responsible for tracking and trending of all infections in the facility.
-The facility reference provided was what the facility were following related to care for resident with COVID-19 per CDC and CMS guidance.
-It was the facility understanding that residents could cohort together due to the positive resident had already exposed the negative roommate to the virus.
-They were to ISO in rooms together.
During an interview on 8/22/23 at 9:48 A.M., Regional Care Coordinator, DON and ADON said:
-The facility had two additional residents (Resident #88 and Resident #609) test positive for COVID-19 after 8/20/23 testing.
During an interview on 8/22/23 at 9:55 A.M., City Health Department staff said:
-He/she was not aware if the facility had notified the City Health Department of any positive COVID-19 infection in the facility.
-COVID-19 positive residents were not to cohort with negative roommates.
-He/she would send the latest information related to care of COVID-19 positive resident.
-He/she would have to follow-up with supervisor related to the facility reporting COVID-19 infection from the facility.
Review of email the DON had received, that was sent to Physician A from Physician B, dated 8/23/23 at 6:42 A.M., showed:
-On 8/22/23 at 8:49 A.M. the Physician A had spoken to Physician B about isolation. It was difficult to isolate in a full building.
-The ideal would be to have an empty room, also cohorting residents.
-But if these options are not available, you would try your best on isolating in the resident room by leaving the curtains closed between resident. With any resident who are asymptomatic, the likelihood of transmission of COVID-19 would be lower.
--Response from Physician B was: he/she agreed, during the quarantine period, the resident should not intermingle with other residents during meals, activities and etc .
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
MO00223251
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Safe Environment
(Tag F0584)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comfortable and homelike environment for 11 s...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comfortable and homelike environment for 11 sampled residents (Residents #304, #69,#600,#621, #617, #96, #601,#603, #18, #508 and #58) out of 17 sampled residents, when they complained that their rooms were hot or had temperatures above 81 degrees Fahrenheit (°F); failed to have a comprehensive monitoring system including documentation for the air temperatures within the resident rooms to maintain comfort level; to maintain documentation for all ongoing maintenance for cooling units in the facility and to conduct random monitoring, or keep record to ensure the comfort of residents in the building. These failures had the potential to affect all residents in the facility. The facility census was 110 residents.
The Administrator was notified on 8/21/23 at 6:09 P.M., of the Immediate Jeopardy (IJ) which began on 8/18/23. The IJ was removed on 8/22/23, as confirmed by surveyor onsite verification.
Review of the facility's Failure of Heating, Ventilation, and Air Conditioning (HVAC) System Policy and Procedure dated 4/1/22 showed:
In the event of all or part of the HVAC system the following steps will be taken include:
-Should a major failure occur to the Central HVAC system (water chiller cooler tower) requiring prolonged shutdown, arrangements have been made for portable emergency air service to provide temporary services until the next system was repaired; Contact contractors listed on the emergency phone list.
-For something other than a major failure, follow the steps below:
--Air Conditioning (AC): check to ascertain if the chillers are operating. Check the unit for the following: Control panel, electric problem, Mechanical failure, and air restriction in cooling tower, water flow in cooling tower, operation of the chill water circulation pumps, and operation of condenser water pump.
--If environmental services department personnel are unable to identify the problem, contact the Director of Environmental services or his/her designee to call in outside contractors.
--Notify house supervisor and administration.
Review of the facility's Code White-Extreme Weather policy dated 11/15/17 showed:
-Provided staff specific guidance and instruction on how to initiate an emergency code and steps to be taken to ensure the safety of residents and staff in the event of extreme weather, temperatures related conditions.
-Know the definition and signs of Heat exhaustion (a disorder resulting from overexposure to heat and sun) and Heat Stroke (a profound disturbance of the body's heat-regulation mechanism, caused by prolonged exposure to excessive heat, particularly when there is little to no circulation of air).
-The following measures should be taken during extreme heat and humidity include:
--Increase fluid intake by providing and encouraging fluids depending upon the individual resident's physical condition and as determined by the nursing staff.
--Encourage resident to wear suitable clothing in the facility, i.e., loose fitting, light weight clothing. Strongly encourage the removal of any additional layers of clothing such as sweater, jackets or hats.
--Encourage resident to reduce or eliminate any strenuous physical activity.
--Discourage resident from going outside and or longer periods of time when the outside temperatures are in 90 degrees Fahrenheit (°F), or if heat index of 90 °F.
--Encourage resident to leave their bedroom doors open to ensure adequate air flow.
--If air conditioning units fail in an area of the facility and or the temperature becomes uncomfortable, upon direction of administrative personnel, resident affected may be moved to another room and or area in the facility where the temperature is adequate.
-Internal building temperatures may be taken in various location of the building, including areas occupied by the residents, at regular intervals particularly between 8:00 A.M. to 10:00 P.M.
-Close the windows, blinds or curtains when exposed to direct sunlight and or hot wind.
-Immediately report any difficulties in the air conditioning unit to the facility Director of Plant Operations.
-Temperatures may be taken by facility director of Plant operations, his/her assistant and or the Nursing supervisor and his/her designee to monitor the temperature and determine the cooler room's area within the facility as necessary.
-Use additional fans in various locations throughout the building to circulate airflow as needed.
Review of the facility's undated Evacuation Instruction sheet showed:
-During a general evacuation of the building, the command post and assembly area will be in the front parking lot in front of the Virgin [NAME] statue.
-Gather ambulatory residents together and appoint staff member to lead them to the assembly area. Do not leave ambulatory residents unattended. Special care residents such as wheelchair (will appoint staff to use any and all wheelchairs to move these resident to the assembly area, when possible staff member will take the wheelchair back to assist in the evacuation), bed confined or total care (could roll bed to the assembly area) , bariatric resident ( don't try move these resident by yourself)
-Once the Evacuation is ordered, call 911 for assistance. Do not assume help is on the way.
--Begin plan designation for staff member and establish command post. You may have to delegate roles to staff members in the absence of front line responders. Follow the producers in the front of the manual for front line responders and make sure if you assign a role to someone, they know what responsibilities they have.
Review of the facility proposal bid for repair of multiple room units dated 5/24/23 showed:
-Units in the Conference Room, room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] all needed a blower motor, capacitor and wheel repair.
-Resident room [ROOM NUMBER] unit required replacement of leaking water valve.
-Resident room [ROOM NUMBER] unit required replacement and Resident room [ROOM NUMBER] unit required a work order to investigate why the unit had no water flow. That investigation may require the shutting down of the facility chiller and pumps.
-Did not have documentation that repairs were made or parts were ordered as of 8/21/23.
Review of the facility proposal bid for replacement of the chiller pump dated 7/10/23 showed:
-The contractor proposes to replace the chiller pump with the newly tested and repaired pump.
--Shut down the chiller loop.
--Disconnect the pump form the piping.
--Use gantry (crane) to lower the pump into the basement.
--Set the newly tested and repaired pump in place.
--Use flex connections to make connections to the existing piping.
--Start the pump and check the operation.
Review of the facility proposal bid for replacement of the exhaust fan dated 7/13/23 showed:
--The contractor proposes to install an exhaust fan for hallway (a six week lead time).
--Disconnect and dispose of the existing exhaust fan.
--Set the new fan on the new curb.
--Connect the new fan to the power and check operations.
Record review of the National Weather Service's official local weather for the city and state where the facility was located from 8/18/23 through 8/22/23, showed the daily high temperatures and heat index were:
-On 8/19/23; Daily High temp of 102°F and heat index 119°F.
-On 8/20/23; Daily High temp of 98°F and heat index 117°F.
-On 8/21/23; Daily High temp of 99°F and heat index 122°F.
-On 8/22/23; Daily High temp of 99°F and heat index 116°F.
Review of the website www.weather.com showed August 19-25, 2023 was a historic heatwave starting on 8/19/23. Well-above normal temperatures impacted the central part of the United States, kicking off a heatwave that has not been experienced in the region in recent history. Kansas City International Airport reached high temperatures not recorded in the area since August of 2012. This stretch of hot weather was accompanied by extremely high dewpoints, with frequently reached the upper 70s to middle 80s across the entire area. The combination of the extreme heat and the excessively high dewpoints led to heat indices from August 19 through August 25 to rise to 120-130 degrees
1. Review of the facility's temperature log sheet dated 8/18/23 showed:
-No identified time.
-Resident room [ROOM NUMBER] was 82.0°F.
-Resident room [ROOM NUMBER] was 82.1°F.
-Resident room [ROOM NUMBER] was 81.5°F.
-Resident room [ROOM NUMBER] was 82.6°F.
-Resident room [ROOM NUMBER] was 86.6°F.
-Resident room [ROOM NUMBER] was 82.9°F.
-Resident room [ROOM NUMBER] was 81.1°F.
-Resident room [ROOM NUMBER] was 81.7°F.
During an interview on 8/19/23 at 11:36 A.M., Activities Director said the facility AC units were in need of repair, so the facility had industrial AC units placed in hallways to assist in keeping the facility cool.
Review of the facility temperature log sheets showed the facility had not collected documentation for resident room temperature checks on 8/19/23 and 8/20/23.
During an interview on 8/21/23 at 9:30 A.M., the Director of Maintenance said:
-The facility room units had an on-off switch, but were mostly controlled by the HVAC chiller systems.
-He/she had been checking the temperatures in the resident rooms, but not over the weekend.
-He/she was off work on the weekend, and he/she had not received any complaints related to excess heat.
-He/she would have come in if he/she were called.
-Temperatures were checked when there were heat advisories.
-There were five Industrial AC cooling units in the hallways to make sure the building was cool.
-A company had given the facility bids on repairs that needed to be done to the cooling system and room units.
-The facility had one chiller for the building and a part had been ordered for that chiller.
-The facility had the chiller pump in, but were waiting on the gantry to lower into the basement.
Review of the facility's temperature log sheet dated 8/21/23 showed:
-No identified time.
-53 resident rooms out of 65 resident rooms temperatures recorded were above 81°F.
-Seven out of 65 resident's room had temperatures above 90.0 °F and with highest was 99.9 °F
--Resident room [ROOM NUMBER] was 90.9 °F.
--Resident room [ROOM NUMBER] was 99.9 °F.
--Resident room [ROOM NUMBER] was 91.9 °F.
--Resident room [ROOM NUMBER] was 91.9 °F
--Resident room [ROOM NUMBER] was 94.9 °F.
--Resident room [ROOM NUMBER] was 92.9 °F.
--Resident room [ROOM NUMBER] was 98.9 °F.
Review of the facility's temperature log sheet dated 8/21/23 at 3:05 P.M. to 3:20 P.M. showed:
-No identified time.
-63 resident rooms out 65 resident rooms temperatures were above 81.0°F.
-Highest temp was in Resident room [ROOM NUMBER] at 95.1 °F.
-18 out of 65 resident's room had temperatures over 90.0 °F include:
--Resident room [ROOM NUMBER] was 90.7 °F.
--Resident room [ROOM NUMBER] was 90.1 °F.
--Resident room [ROOM NUMBER] was 90.5 °F.
--Resident room [ROOM NUMBER] was 94.2 °F
--Resident room [ROOM NUMBER] was 94.5 °F.
--Resident room [ROOM NUMBER] was 92.9 °F.
--Resident room [ROOM NUMBER] was 90.9 °F.
--Resident room [ROOM NUMBER] was 90.7 °F.
--Resident room [ROOM NUMBER] was 92.2 °F.
--Resident room [ROOM NUMBER] was 92.2 °F.
--Resident room [ROOM NUMBER] was 91.5 °F.
--Resident room [ROOM NUMBER] was 95.1 °F.
--Resident room [ROOM NUMBER] was 95.0 °F.
--Resident room [ROOM NUMBER] was 94.3 °F.
--Resident room [ROOM NUMBER] was 90.0 °F.
--Resident room [ROOM NUMBER] was 91.2 °F.
--Resident room [ROOM NUMBER] was 90.4 °F.
--Resident room [ROOM NUMBER] was 90.0 °F. (isolation room)
Observation and interview on 8/21/23 at 3:20 P.M., Maintenance Assistant showed:
-Checking resident room temperature by pointing the Infrared Thermometer Testers toward the resident room ceiling. The facility infrared thermometer had Resident room [ROOM NUMBER] at 95.5 °F.
-He/she said this was the hottest room found at that time.
Observation on 8/21/23 from 3:25 P.M. to 4:02 P.M., showed:
-Resident room [ROOM NUMBER] was 84.3 °F.
-Resident room [ROOM NUMBER] was 86.3 °F.
-Resident room [ROOM NUMBER] was 85.6 °F.
-Resident room [ROOM NUMBER] was 87.4 °F.
-Resident room [ROOM NUMBER] was 85.7 °F.
-Resident room [ROOM NUMBER] was 87.4 °F.
-Resident room [ROOM NUMBER] was 90.5 °F.
-Resident room [ROOM NUMBER] was 88.4 °F.
-The hallway outside of Resident room [ROOM NUMBER] was 85.5 °F.
-The hallway outside of Resident room [ROOM NUMBER] was 85.5 °F.
-The hallway outside of Resident room [ROOM NUMBER] was 84.0 °F.
Review of Resident #304 Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 5/24/23, showed he/she:
-Had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) of 12.
-He/she was able to understand others and make his/her needs known.
Observation and interview on 8/21/23 at 3:38 P.M., the resident said:
-The room AC unit had slight air blowing from the unit.
-The resident's hair was wet from sweating.
-He/she said it was too hot to move around too much.
-He/she had fans in the room and the fans did not really help with cooling his/her room.
-The room AC unit had not been working very well for a long time.
-His/her room and the facility had been hot for several days and was worse at night.
-The room temperature was 90.5 °F.
Review of Resident #69's Quarterly MDS dated [DATE], showed he/she:
-Was cognitively intact with a BIMS score of 13.
-He/she was able to understand others and make his/her needs known.
Observation and interview on 8/21/23 at 3:40 P.M., the resident said:
-The room AC unit had slight air blowing from the unit.
-The resident was sweating while laid in bed.
-He/she had two fans in room and he/she felt the fans really did not help with cooling the room down.
-His/her room and the facility had been hot for several days.
-The room temperature was 89.6 °F.
During an interview on 8/21/23 at 4:20 P.M., Certified Medication Technician (CMT) B said:
-The facility had been hot like this for a little over a week.
-Most of the resident rooms were hot.
-Residents had not really complained about being hot.
-He/she had asthma and the heat bothered him/her.
-He/she took her breaks in his/her car so he/she could use the air conditioning.
Review of Resident #96's Quarterly MDS dated [DATE], showed he/she:
-Was cognitively intact with a BIMS score of 15.
-He/she was able to understand others and make his/her needs known.
Observation and interview on 8/21/23 at 4:25 P.M., the resident said:
-He/she was hot.
-His/her room had been hot like this the past few days.
-He/she had a tracheostomy (surgical opening in the trachea to assist with breathing), and the humidity was making it harder to breathe, more than the heat.
-The room was 89.0 °F.
Review of Resident #601's Quarterly MDS dated [DATE], showed he/she:
-Was cognitively intact with a BIMS score of 15.
-He/she was able to understand others and make his/her needs known.
Observation and interview on 8/21/23 at 4:30 P.M., the resident said:
-The day before, his/her blood pressure had been 180/100 (normal range 120/70).
-He/she had high blood pressure, but he/she thought the heat made it worse.
-He/she thought the heat made it harder to sleep and to breathe.
-He/she had been at the facility over a month and the air conditioning had not been working properly the whole time.
-The room was 89.2 °F.
Review of Resident #603's Quarterly MDS dated [DATE], showed he/she:
-Was cognitively intact with a BIMS score of 14.
-He/she was able to understand others and make his/her needs known.
Observation and interview on 8/21/23 at 4:30 P.M., the resident said:
-He/she had asthma and COPD.
-He/she was on oxygen.
-He/she had trouble breathing because of the heat.
-The heat made him/her feel dizzy, light-headed and sick to his/her stomach.
-It had been hot in the facility since the end of July.
-The room was 89.2 °F.
Review of Resident #18's Quarterly MDS dated [DATE], showed he/she:
-Was moderately cognitively impaired with a BIMS score of 9.
-He/she was able to understand others and make his/her needs known.
Observation and interview on 8/21/23 at 4:35 P.M., the resident said:
-He/she was on oxygen.
-The heat made it harder for him/her to breathe.
-It had been hot all summer.
-It was even hotter when the sun came through his/her window.
-It was also hot in the dining room and activity room.
-The room was 90.3 °F.
Observation on 8/21/23 at 4:20 P.M. to 4:50 P.M., showed:
-Resident room [ROOM NUMBER] was 87.8 °F.
-Resident room [ROOM NUMBER] was 84.5 °F.
-Resident room [ROOM NUMBER] was 84.8 °F.
-Resident room [ROOM NUMBER] was 89.6 °F and the door was shut.
-Resident room [ROOM NUMBER] was 89.2 °F with two bed bound residents.
-The hallway outside of Resident room [ROOM NUMBER] was 83.8 °F.
-The facility main dining room was 82.0 °F with 10 residents in the space.
Review of Resident #621's Quarterly MDS, dated [DATE], showed he/she:
-Was cognitive intact with BIMS of 13.
-He/she was able to understand others and make his/her needs known.
-Required the use of wheelchair for mobility.
-Impairment of both lower extremities.
Observation and interview on 8/21/23 at 4:21 P.M., the resident said:
-The AC unit had no air blowing.
-He/she said the room AC unit had been broken for a while.
-The resident had four fans in use in the room and the resident were sweaty.
-He/she said it had been very hot in room for several days and was he/she had difficulty sleeping in the heat.
Review of Resident #600's Quarterly MDS dated [DATE], showed he/she:
-Was cognitive intact with BIMS of 15.
-He/she was able to understand others and make his/her needs known.
-Required total assistant of two staff member for transfer and all cares.
-Required the use of oxygen.
Observation and interview on 8/21/23 at 4:40 P.M., the resident said:
-He/she was having a hard time catching his/her breathe with the increased temperature in the facility.
-He/she had oxygen in place.
-The AC unit had slight air movement from the unit.
-The resident had a box fan running in room, the window blinds closed and the light off.
-He/she had a sheet covering the lower half his/her body.
-The room temperature was 83.5 °F.
During an interview on 8/21/23 at 4:40 P.M., Certified Nurse Aide (CNA) C said:
-Some of the residents had complained of being hot.
-He/she had not done anything, as none of the residents had negative outcomes that he/she was aware of.
During an interview on 8/21/23 at 5:00 P.M., Receptionist B said:
-Ice water was available to the residents at all times.
-He/she was on oxygen and the heat made it harder to breathe.
During an interview on 8/21/23 at 5:55 P.M., the Director of Maintenance said:
-There was one chiller for the facility and it was currently on.
-The chiller and pump were working, just not efficiently keeping up with the demand.
-A replacement pump had to be installed.
-A crane would have to be used to put the pump in place.
-An exhaust fan was also needed on the roof. The air conditioner company was trying to get it all done in one day.
-The same company was also going to fix room blower/capacitor parts.
During an interview on 8/21/23 at 6:09 P.M., the Administrator, Regional Support specialist, and Regional Care Coordinator said:
-Four additional industrial AC units and 30 box fans had been added to the facility and the facility was not able to maintain the regulation of 71°F to 81°F for resident comfort and safety.
-Their review of the facility's temperature log found the highest temperature of 95.5 °F in the building and the lowest temperature found was 81°F.
Observation on 8/21/23 at 7:40 P.M., showed the contracted AC Repair Company arrived at the facility to evaluate and repair the facility's HVAC chiller system unit.
During an interview on 8/21/23 at 8:28 P.M., the Administrator said:
-On Sunday 8/20/23 it had been reported to him/her the facility air temperatures were increasing and not maintained in range of 71 °F to 81°F.
-The facility had planned on Monday 8/21/23 to increase the number of industrial AC units in the buildings.
-The facility had obtained four more industrial AC units in the morning of 8/21/23.
-The facility contracted AC repair staff thought they would be able to get the chiller working completed that night or first thing in morning.
-The facility was working on an evacuation plan if unable to fix the facility HVAC system or if the facility was unable to maintain temperatures within the range of 71-81 °F.
Observation on 8/21/23 at 8:30 P.M. to 8:55 P.M., showed:
-Resident room [ROOM NUMBER] 86.5 °F.
-Resident room [ROOM NUMBER] was 86.7 °F, the door was shut.
-Resident room [ROOM NUMBER] was 84.5 °F.
-Resident room [ROOM NUMBER] was 86.7 °F.
-Resident room [ROOM NUMBER] was 85.6 °F.
-Resident room [ROOM NUMBER] was 84.3 °F, the door was shut.
-Resident room [ROOM NUMBER] was 82.8 °F.
-Resident room [ROOM NUMBER] was 87 °F.
-Resident room [ROOM NUMBER] was 88.9 °F.
-Resident room [ROOM NUMBER] was 87.9 °F,
-Resident room [ROOM NUMBER] was 88.9 °F.
-Resident room [ROOM NUMBER] was 81.9 °F.
-The hallway outside of room [ROOM NUMBER] and room [ROOM NUMBER] was 83.4 °F.
Observation and interview on 8/21/23 at 8:42 P.M., Resident #600 said:
-He/she was more anxious and still heavy breathing
-The room temperature was 81.5 °F.
During an interview on 8/21/23 at 9:50 P.M., the Administrator said:
-The AC contractor was able to fix the loop on the chiller.
-The facility HVAC system also had blockage of the water systems that supplies water to the HVAC chiller units.
-The AC contractor said it could take a while to cool down the facility, since there was such high temperatures in the building and it could possibly take two days to cool down.
-The facility was aware of four room units that were not working and were waiting on parts for those room units.
Observation on 8/21/23 at 10:55 P.M. to 11:03 P.M., showed:
-Resident room [ROOM NUMBER] was 86.3 °F, the door was shut.
-Resident room [ROOM NUMBER] was 87.2 °F.
-Resident room [ROOM NUMBER] was 87.2 °F, the door was shut.
Observation on 8/22/23 at 12:00 A.M. to 1:00 A.M., with facility Administrator and Director of Nursing (DON) showed there were 46 resident rooms out of 65 resident rooms recorded over 81°F.
-Resident room [ROOM NUMBER] had highest temp of 88.5°F, the room AC was not on.
Observation and interview on 8/22/23 at 8:44 AM., Resident #621 showed:
-He/she said the AC unit in room was broken.
-Had not been working for several months.
-He/she said the temperature had improved overnight but was still hot in room.
-The temperature was 82.9 °F.
Observation on 8/22/23 at 8:44 A.M. to 8:52 A.M., showed:
-Resident room [ROOM NUMBER] was 85.2 °F.
-Resident room [ROOM NUMBER] was 85.8 °F.
-Resident room [ROOM NUMBER] was 86.1 °F.
-Resident room [ROOM NUMBER] was 85.6 °F.
-Resident room [ROOM NUMBER] was 87 °F.
-Resident room [ROOM NUMBER] was 95.1 °F.
-Resident room [ROOM NUMBER] was 95.5 °F.
-Resident room [ROOM NUMBER] was 94.4 °F.
-Resident room [ROOM NUMBER] was 93 °F.
-Resident room [ROOM NUMBER] was 87.8 °F.
-Resident room [ROOM NUMBER] was 85.3 °F.
-Resident room [ROOM NUMBER] was 84.2 °F.
-Resident room [ROOM NUMBER] was 84.2 °F.
During an interview on 8/22/23 at 9:00 A.M., the Administration said:
-The facility HVAC chiller unit had stopped working again and the facility building and resident room temperatures were increasing.
-The facility had already sent out seven COVID-19 positive residents to three different hospitals.
Review of Resident #617's Quarterly MDS, dated [DATE], showed he/she:
-Was severely cognitive impairment.
-He/she was able to understand others and make his/her needs known.
-Required the use of a wheelchair.
-Required limited assistance with all cares of one staff member.
-Had a diagnosis of Parkinson disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).
Observation on 8/22/23 between 3:00 P.M. to 4:30 P.M., of the resident showed:
-He/she was sitting in a wheelchair by the front desk, when unknown facility staff noticed the resident was sweaty, and had slow response to commands, the staff person moved the resident toward to the fans.
-Nursing staff assessed the resident to include vital signs and applied ice to back of the resident neck.
-Fire first responder personal who were onsite to evacuate, reassessed the resident and made the decision to call for an ambulance to transport the resident to the hospital for further evaluation and treatment.
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level L. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to recognize the need to evacuate the fac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to recognize the need to evacuate the facility after temperatures exceeded regulatory requirements for an extended amount of time and to ensure their emergency plan was developed to include all required components. Additionally, the facility failed to evacuate the residents in an orderly, organized manner, which included finding placement and transportation for residents, sending residents medical records, medications, code status, COVID 19 status, and staff with residents to the receiving facilities. The failures delayed evacuation and jeopardized the health and safety for all residents and staff. The facility census was 110 residents.
The Administrator was notified on [DATE] at 10:15 A.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification.
Review of the facility's undated Evacuation Instruction sheet showed:
-During a general evacuation of the building, the command post and assembly area will be in the front parking lot in front of the Virgin [NAME] statue.
-Gather ambulatory residents together and appoint staff member to lead them to the assembly area. Do not leave ambulatory residents unattended. Special care residents such as wheelchair (will appoint staff to use any and all wheelchairs to move these resident to the assembly area, when possible staff member will take the wheelchair back to assist in the evacuation), bed confined or total care (could roll bed to the assembly area), bariatric resident (don't try move these resident by yourself).
-Once the Evacuation is ordered, call 911 for assistance. Do not assume help is on the way.
--Begin plan designation for staff member and establish command post. You may have to delegate roles to staff members in the absence of front line responders. Follow the producers in the front of the manual for front line responders and make sure if you assign a role to someone, they know what responsibilities they have.
Review of the facility's Code White-Extreme Weather policy, dated [DATE], section of the Facility's Emergency preparedness binder showed:
-Provided staff specific guidance and instruction on how to initiate an emergency code and steps to be taken to ensure the safety of resident and staff in the event of extreme weather, temperatures related conditions.
-Know the definition and signs of Heat exhaustion (a disorder resulting from overexposure to heat and sun) and Heat Stroke (a profound disturbance of the body's heat-regulation mechanism, caused by prolonged exposure to excessive heat, particularly when there is little to no circulation of air).
-The following measures should be taken during extreme heat and humidity include:
--Increase fluid intake by providing and encouraging fluids depending upon the individual resident's physical condition and as determined by the nursing staff.
--Encourage resident to wear suitable clothing in the facility, i.e., loose fitting, light weight clothing. Strongly encourage the removal of any additional layers of clothing such as sweater, jackets or hats.
--Encourage resident to reduce or eliminate any strenuous physical activity.
--Discourage resident from going outside and or longer periods of time when the outside temperatures are in 90 degrees Fahrenheit (°F), or if heat index of 90°F.
--Encourage resident to leave their bedroom doors open to ensure adequate air flow.
--If air conditioning units fail in an area of the facility and or the temperature becomes uncomfortable, upon direction of administrative personnel, resident affected may be moved to another room and or area in the facility where the temperature is adequate.
-Internal building temperatures may be taken in various location of the building, including areas occupied by the residents, at regular intervals particularly between 8:00 A.M. to 10:00 P.M.
-Close the windows, blinds or curtains when exposed to direct sunlight and or hot wind.
-Immediately report any difficulties in the air conditioning unit to the facility Director of Plant Operations.
-Temperatures may be taken by facility Director of Plant operations, his/her assistant and or the Nursing supervisor and his/her designee to monitor the temperature and determine the cooler room's area within the facility as necessary.
-Use additional fans in various locations throughout the building to circulate airflow as needed.
Review of the facility undated emergency red book contacts showed:
-The facility number one place for resident evacuation was not a home in the area.
-Had number of roof top air conditioners contractor.
-Express Transportation.
-A boiler contract company.
-A list of area Emergency Coordinator and phone numbers.
-Facility Administration staff and numbers.
Review of the facility's emergency preparedness plan in a binder entitled Emergency Operations Plan, obtained from the nurse station and last revised on [DATE], showed the following:
-On pages #21 and #22 with the headings Extreme Weather - Cold and Extreme Weather - Hot, neither policy mentioned a procedural method to maintain temperatures in resident areas at comfortable and safe levels at all times in the event of a power outage and/or HVAC failure, including what those levels are (71 to 81 degrees Fahrenheit), who would be responsible for monitoring the inside temperatures, where they would be measured, what means would be used to measure them, and how often they would be measured.
Review of the National Weather Service Website showed an [DATE]-25 Historic Heatwave. Starting on [DATE] well-above normal temperatures impacted the central part of the United States, kicking off a heatwave that has not been experienced in the region in recent history. Kansas City International Airport reached high temperatures not recorded in the area since August of 2012. This stretch of hot weather was accompanied by extremely high dewpoints, which frequently reached the upper 70s to middle 80s across the entire area. The combination of the extreme heat and the excessively high dewpoints led to heat indices from [DATE] through [DATE] to rise to 120-130 degrees.
Review of Climatological Data for Kansas City Area, MO (ThreadEx), dated [DATE], showed:
-On [DATE], the maximum temperature was 102°F, the minimum temperature was 73°F and the average temperature was 83.5°F. Heat index was 119°F.
-On [DATE], the maximum temperature was 98°F, the minimum temperature was 77°F and the average temperature was 85.5°F. Heat index was 117°F.
-On [DATE], the maximum temperature was 99°F, the minimum temperature was 80°F and the average temperature was 87.5°F. Heat index was 122°F.
-On [DATE], the maximum temperature was 99°F, the minimum temperature was 79°F and the average temperature was 86°F. Heat index was 116°F.
1. During interviews on [DATE] at 9:50 A.M. and 8:28 P.M., the Administrator said:
-On Sunday [DATE] it had been reported to him/her the facility air temperatures were increasing and not maintained in range of 71 °F to 81°F.
-The facility plan on Monday [DATE] was to increase the number of industrial AC units in the buildings.
-The facility had obtained four more industrial AC units that morning.
-The AC contractor had been at the facility and was able to fix the loop on the chiller.
-The facility HVAC system also had a blockage of the water systems that supplies water to the HVAC units and would need to be fixed.
-AC contractor said the facility building could take a while to cool down since it had such high temperature in the building (Possible one to two days to cool down the building).
-The facility was aware four room units were not working, were waiting on parts to fix those units and residents remained in those rooms with AC units not working.
Observation on [DATE] from 3:25 P.M. to 4:02 P.M., showed:
-Resident room [ROOM NUMBER] was 84.3 °F.
-Resident room [ROOM NUMBER] was 86.3 °F.
-Resident room [ROOM NUMBER] was 85.6 °F.
-Resident room [ROOM NUMBER] was 87.4 °F.
-Resident room [ROOM NUMBER] was 85.7 °F.
-Resident room [ROOM NUMBER] was 87.4 °F.
-Resident room [ROOM NUMBER] was 90.5 °F.
-Resident room [ROOM NUMBER] was 88.4 °F.
-The hallway outside of resident room [ROOM NUMBER] was 85.5 °F.
-The hallway outside of resident room [ROOM NUMBER] was 85.5 °F.
-The hallway outside of resident room [ROOM NUMBER] was 84.0 °F.
Observation on [DATE] at 4:20 P.M. to 4:50 P.M., showed:
-Resident room [ROOM NUMBER] was 87.8 °F.
-Resident room [ROOM NUMBER] was 84.5 °F.
-Resident room [ROOM NUMBER] was 84.8 °F.
-Resident room [ROOM NUMBER], the A/C unit had no air, there were four fans in use in the room and the resident's hair was wet from sweating.
-Resident room [ROOM NUMBER] was 89.6 °F and the door was found shut.
-Resident room [ROOM NUMBER] was 89.2 °F with two bed bound residents.
-The hallway outside of room [ROOM NUMBER] was 83.8 °F.
-The facility main dining room was 82.0 °F with 10 residents in the space.
During an interview on [DATE] at 6:09 P.M., the Administrator, Regional Support Specialist, and Regional Care Coordinator said:
-Four additional industrial AC units and 30 box fans had been added to the facility and the facility was not able to maintain the regulation of 71°F to 81°F for resident comfort and safety.
-Their review of the facility's temperature log found the highest temperature of 95.5°F in the building and the lowest temperature found was 81°F.
-The plan was to shelter in place as it was resident rights.
During an interview on [DATE] at 6:50 P.M., the Administrator said:
-The HVAC company would be on-site in the next 30 minutes to assess the whole system.
-The facility had 10 large air conditioner units already and another 4 were being delivered the next morning.
-They could not get the units that night, because there was nobody to deliver them.
-The plan was to do temperature checks every three hours.
-The director of maintenance was checking them at that time.
-He/she would check the temperatures at 10:00 P.M., and the front door person would check them during the night.
-There was an evacuation plan, which was to move as many residents as possible to sister facilities located in Festus, Missouri which is four hours from the facility and Toganoxie, Kansas which is 40 minute trip.
-The facility had two buses.
-The staff were checking the residents to make sure they had fans and water, and were doing okay.
-Ice water would be given to everyone.
During an interview on [DATE] at 8:28 P.M., the Administrator said:
-The facility contracted AC repair staff thought they would be able to get the chiller to work completed that night or first thing in morning.
-The facility was working on an evacuation plan of the building, if the facility was unable to fix the HVAC system or if the facility was unable to maintain temperature within the range of 71-81 °F.
Observation on [DATE] at 8:30 P.M. to 8:55 P.M., showed:
-Resident room [ROOM NUMBER] 86.5 °F.
-Resident room [ROOM NUMBER] was 86.7 °F, the door was shut.
-Resident room [ROOM NUMBER] was 84.5 °F.
-Resident room [ROOM NUMBER] was 86.7 °F.
-Resident room [ROOM NUMBER] was 85.6 °F.
-Resident room [ROOM NUMBER] was 84.3 °F, the door was shut.
-Resident room [ROOM NUMBER] was 82.8 °F.
-Resident room [ROOM NUMBER] was 87 °F.
-Resident room [ROOM NUMBER] was 88.9 °F.
-Resident room [ROOM NUMBER] was 87.9 °F,
-Resident room [ROOM NUMBER] was 88.9 °F.
-Resident room [ROOM NUMBER] was 81.9 °F.
-The hallway outside of room [ROOM NUMBER] and 215 was 83.4 °F.
Observation on [DATE] at 8:44 A.M. to 8:52 A.M., showed:
-Resident room [ROOM NUMBER] was 85.2 °F.
-Resident room [ROOM NUMBER] was 85.8 °F.
-Resident room [ROOM NUMBER] was 86.1 °F.
-Resident room [ROOM NUMBER] was 85.6 °F.
-Resident room [ROOM NUMBER] was 87 °F.
-Resident room [ROOM NUMBER] was 95.1 °F.
-Resident room [ROOM NUMBER] was 95.5 °F.
-Resident room [ROOM NUMBER] was 94.4 °F.
-Resident room [ROOM NUMBER] was 93 °F.
-Resident room [ROOM NUMBER] was 87.8 °F.
-Resident room [ROOM NUMBER] was 85.3 °F.
-Resident room [ROOM NUMBER] was 84.2 °F.
-Resident room [ROOM NUMBER] was 84.2 °F.
During an interview on [DATE] at 9:00 A.M., the Administration said:
-The facility HVAC chiller unit had stopped working again and the facility room temperatures were increasing.
-The facility had already sent out seven COVID-19 positive residents to three different hospitals.
During an interview on [DATE] at 9:48 P.M., Regional Care Coordinator, Director of Nurses (DON) and Assistant Director of Nurses (ADON) said:
-The facility administration had asked all residents if they wanted to shelter in place at the facility or to leave the facility.
-The facility administration said they had a combination of resident for both options.
-Those residents requesting to leave the facility would be sent to assigned facilities and other residents would be shelter in place at the facility.
-The facility was working on making the main dining area and that hallway the cooling center for the facility.
-Plans were to bring in resident beds for those resident who required or wish to stay to dining area.
-The facility also ensured one shower room would be setup as cooling place to be able to continue resident personal care needs and located on the 100 hallway.
-The AC contracted company would be at the facility as soon as possible, to place the new chiller pump and to flush pump system.
-The facility was having more AC industrial units delivered that morning.
-Seven residents had already been sent to three different hospital due to COVID-19 positive.
-The facility had two additional residents test positive for COVID-19.
-The facility felt the temperature were coming down slowly.
-It was arranged for a sister facility or an area facility to take 50 residents and another would take 30 residents.
-The facility was in process of making a tracking form for where the residents would be assigned to go.
Observation on [DATE] at 9:45 A.M., showed:
-Staff were informing other staff the evacuation would take place and residents had a choice whether or not to evacuate.
-Staff were told they would go with residents to the receiving facilities.
During an interview on [DATE] at 10:00 A.M., the Regional Care Coordinator said:
-Residents were sheltering in place in the 200 hall.
-The temperature was coming down in the dining room.
-They were trying to work out how many beds would fit in the dining room.
-If they were not able to get that area chilled, all residents would be transferred out.
-Elopement residents would be requested to transfer to a facility with a locked unit, who would keep them even after an evacuation.
-Seven residents had been transferred to three different hospitals due to being COVID-19 positive.
Observation on [DATE] at 10:25 A.M., the main entrance area showed two residents with suit cases out 6 resident that were in the entrance area, and waiting to be transported to another facility.
Observation on [DATE] at 10:50 A.M., showed:
-Several shirtless residents were observed to be congregating in the 100 hallway and another was only wearing shorts sitting in a wheelchair.
-Many residents were still in bed or watching television.
-Staff were checking room temperatures from the doorways.
Observation on [DATE] at 1:10 P.M., showed the back 200 hallway was blocked off with all facility medication carts as the DON, ADON, and unknown CMT sorted through medication to be sent with the residents who were leaving the facility.
Observation on [DATE] at 1:14 P.M., showed the city Emergency Management Team arrived at the facility and was observed coordinating with facility administration staff on the facility plan for evacuation of all residents.
Observation on [DATE] at 2:05 P.M., showed the first load of residents left the facility in a large city bus and smaller bus. No medical record paperwork was sent with the residents.
Observation on [DATE] at 3:15 P.M., showed the next bus loaded with residents with their facesheets left for a receiving facility.
Observation and interview on [DATE] at 7:09 P.M., the Administrator said:
-He/she was going to all facilities to follow-up on the residents and deliver residents medication where needed.
-The last resident signed out and left the facility with a family member.
-The facility had completely evacuated all resident from the facility.
During an interview on [DATE] at 3:20 P.M., the Assistant Director of Nursing (ADON) said:
-He/She could not say they had evacuation training during orientation.
-During the evacuation, the unit nurses would have been in charge of assigning staff where to go and what to do.
-He/She had provided oversight, resident medications were being pulled for each resident and sent to the appropriate facility.
-The staff worked together to print the residents' paperwork.
-He/She thought most facilities could have done their evacuation process very quickly.
-He/She wanted the residents to be moving with urgency related to the emergency.
-He/She did not know if the certified nurse aides (CNAs) were assigned to tasks.
-He/She was providing oversight for the process.
-He/She thought the Director of Nursing (DON) had the emergency book that had all residents' face sheets and physician order sheets, so if there was a problem during the process there would be a backup plan.
During an interview on [DATE] at 8:55 A.M., Administrator B said:
-The facility Administrator had called them to see if they had beds available to take residents as they were evacuating.
-22 residents arrived from the facility on [DATE] with no face sheets, no medications, no belongings, and no code status.
-He/she had sent his/her staff to the facility in the evening of [DATE] to attempt to get some of the resident medications and belongings.
-No facility staff were sent with the facility residents on [DATE] or thereafter to assist.
During an interview on [DATE] at 12:10 P.M., CNA G said:
-When it was time for the residents to be evacuated he/she was instructed to bring the residents to the lobby by the DON, with two to three days worth clothing.
-The DON was instructing the staff where the residents were to be going.
-He/She did not ride with any residents during the evacuation.
-He/She was told to report to the new facility the next day and he/she did.
During an interview on [DATE] at 12:15 P.M., CNA H said:
-His/Her role during the evacuation was to pack clothing, pass water, and take residents outside to the transportation.
-He/She was supposed to ensure each resident had two to three changes of clothing, a water bottle, and any small personal items the resident wanted.
-When he/she took the residents outside there was a checklist of which residents were going to which facility and on what bus the resident was to go.
-The checklist was being managed by CNA F and you would check in with him/her and be told where to take the resident.
-No one from the facility notified him/her where the residents were going.
-When he/she took the residents out the CNA with the clipboard would tell him/her where the residents were going, but the fire department, and the ambulances were also telling him/her where residents were going.
-There was no single point of contact to find out where the residents were going. It was very chaotic.
-He/She did not ride any of the buses with the residents evacuated.
-The DON and administration were telling staff where to go and when to be there.
During an interview on [DATE] at 12:40 P.M., CNA J said:
-He/She was off the day of the evacuation.
-No one from the facility called to have him/her report for the emergency.
-He/She called the staffing office when he/she heard of the evacuation from coworkers who had texted and called him/her and advised of the situation to find out where she was to report to.
-He/She was given the choice of three facilities and he/she chose the facility where to report to and today was his/her first day to work.
During an interview on [DATE] at 12:45 P.M., Registered Nurse (RN) A said:
-During the evacuation he/she assisted in getting all the residents property together, and ensured the residents were taken up to the lobby.
-The residents were to have two changes of clothing.
-Other nurses and Certified Medication Technicians (CMT) were boxing up medications and the mediations were to be sent later.
-The DON, ADON, a nurse, and CMT delivered the medications for the residents to the facilities where the residents were at.
-The front office was in charge of the medical records to include the do not resuscitate (DNR) forms.
-The DNR form should have been a part of the medical record.
-He/She was given a piece of paper to where the residents were to go by administration, but which resident was going to which facility kept changing.
-He/She did not ride with any resident on the evacuation transportation.
-He/She was told by staffing where to respond.
During an interview on [DATE] at 12:59 P.M., CNA D said:
-His/Her role during the evacuation was to work the front desk answering the phones and monitoring the residents in the lobby.
-When it was time, he/she would help the residents to the buses for evacuation.
-He/She would take the residents out of the building and proceed to the buses where the firefighters and ambulance crews told him/her which bus to put residents on, and no one from the facility was directing which bus the residents were to get on or which facility the resident was to go.
-He/She stayed at the facility to help with the evacuation and did not ride on any of the buses with the residents.
-He/She was told to report to the new facility on [DATE].
During an interview on [DATE] at 1:05 P.M., Licensed Practical Nurse (LPN) C said:
-He/She was at home and off work during the evacuation.
-The facility did not call him/her to come in for the emergency.
-He/She went to work at the evacuated facility on [DATE] and was told to which facility he/she needed to respond to.
During an interview on [DATE] at 1:19 P.M., Graduate Nurse (GN) A said:
-He/She was not part of the evacuation.
-Human Resources called him/her at home and told her which facility he/she would need to report to.
During an interview on [DATE] at 1:34 P.M., CMT D said:
-He/She was helping to get the residents medication together and helping get residents to the lobby for evacuation.
-Each resident was to have two to three days worth of clothing along with briefs, and whatever small personal items they wanted to bring.
-The resident's medications were put on the transportation bus for the residents on the bus.
-Social Services was faxing all the residents' medical records to the receiving facilities.
-The signed DNR forms should have been faxed to the receiving facilities along with the medical records.
-He/She did not help take the residents from the lobby to the buses.
-He/She was getting the medication boxes organized, labeled with receiving facility name and all the residents going to that facility had the medications placed in the box.
-The box was then taken to the bus by staff.
-He/She could not remember which staff were taking medications to which bus.
-Human Resources gave him/her a list of names by receiving facility and which residents were going to that facility, and that was how he/she packaged the medication by facility per resident.
-He/She did not ride in any of the buses with the residents he/she stayed at the evacuated facility to help out there until 8:30 P.M.
-The staffing coordinator told him/her which facility to report to on [DATE] and he/she was to stay at that facility until told to return to the evacuated facility.
During an interview on [DATE] at 10:11 A.M., Fire Department Division Chief for EMS (Emergency Medical Services) said:
-On [DATE] the facility had two call outs, he/she was part of the first call out to transport 7 COVID-19 positive residents to the hospital since they were not tolerating the heat well.
-When he/she arrived to the facility, one [NAME] and ambulances had begun to arrive.
-The facility staff had provided facesheets for the residents and his/her team took the residents to their hospital of choice.
During an interview on [DATE] at 10:29 A.M., Fire Department Deputy Chief EMS said:
-He/she was part of the facility evacuation on the second round.
-Agencies involved included, the fire department, the local police for traffic control, the city buses, Mid America Regional Council, KC Emergency Operation Center.
-2 strike teams were designated for the facility evacuation.
-His/her staff had followed procedures, went down each hallway checked every room, every closet, bathroom and would shut the door when the space was cleared.
-The facility staff would go behind the emergency personnel and reopen the doors, take residents back down the hallways to their rooms after the area had been cleared causing emergency personnel to have to start over.
-No staff would acknowledge who was in charge, when asked the staff would scatter.
-Staff dressed in business casual were noted in business offices with portable A/C units while the fire department did the heavy lifting and denied being in charge.
-The facility staff and facility administration were of no assist.
-He/she gave the facility administration over two hours to provide a manifest (list of residents and what locations) to evacuate when he/she took over about 3:00 P.M.
-He/she had residents placed on buses, facility staff would take the residents off the buses and ask the residents what facility they wanted to go to.
-The Administrator said they needed to give the residents a choice.
-He/she told the Administrator it was only getting hotter, it was the hottest day of the year and there was not a choice.
-About 1:20 P.M., the fire department had brought misters (spraying water) and placed outside, as well as water bottles and cups. The facility had only one carafe set-up for a hydration station for the residents.
-Not a single facility staff person would say they were in charge.
-He/she asked more than once who was in charge.
-He/she asked more than once for the facility emergency plan and did not receive it.
-Most of the residents were lovely, all who could verbalize said they were hot, many had questions as to what was happening.
-One resident did become angry, refused to get on a bus, was hostile with the facility staff and emergency personnel, he/she confirmed the resident was his/her own person and the resident took off on foot. No staff jumped in to follow the resident as he/she took off and attempt to redirect.
-The facility had one bariatric resident who was in the back of the building and bed bound. No facility staff reported he/she was back there until EMS personnel found them when clearing the halls.
-He/she was told the facility had 7 residents who could not just go anywhere, he/she asked the facility staff to gather these residents in one place and transport would be arranged, the staff would not cooperate or coordinate.
-No medications or paperwork went on the buses with any residents.
-No facility staff went on the buses to assist with the residents, only EMS personnel.
-3 city buses were provided for the evacuation.
-The Mass Casualty Trailer (MCT) was brought onsite to have emergency supplies available.
-The facility was hot, the residents were visibly hot and perspiring, the EMS personnel was soaked in perspiration down to the undergarments.
-The Administrator tried to say EMS needed to give them a chance to ask the residents what they wanted, he/she told him it did not work that way.
-The last residents were removed form the building by them at 5:59 P.M.
During an interview on [DATE] at 11:12 A.M., Administrator C said:
-On [DATE]:
--The facility Administrator had made contact about 8:00 A.M., and asked if resident beds were available for an evacuation.
--At 11:30 A.M., the facility Business Office Manager sent a list of people, including a list of COVID-19 positive residents that were sent to the hospital as possible temporary admissions.
--At 2:30 P.M., 2 city buses showed up with 28 residents, none had their medications, some had facesheets, and there were no staff present.
--Some of the residents who arrived on the buses were not on the resident list emailed previously.
--The facility had called later and asked if staff were needed, the answer was yes and staff arrived about dinner time.
--At 6:23 P.M., a medication cart arrived at the facility with some of the residents medication.
--At 10:15 P.M., the medications for the remaining residents were sent.
-On [DATE] it was observed the residents had needed psychosocial supports, the facility was contacted and requested to send over their social worker, the social worker was out and no staff were sent to support the psychosocial needs of the residents.
-The facility did not provide an order or documentation for the residents DNR resulting in one resident on [DATE] who was a DNR status to have life saving measures including cardio pulmonary resuscitation (CPR) during a cardiac event.
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level L. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
MO00223378
Jun 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #306, #55 an...
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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 three sampled residents (Resident #306, #55 and #307) were free from abuse. On 5/31/23, Resident #308 hit Resident #307 with a cane, causing a skin tear above the resident's right eye. On 6/2/23, Resident #305 groped Resident #55's breast and on 6/3/23, Resident #305 struck Resident #306 in the resident's head out of eight sampled residents. The facility census was 105 residents.
Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, showed:
-Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including:
--facility staff.
--other residents.
--consultants.
--volunteers.
--staff from other agencies.
--family members.
--legal representatives.
--friends.
--visitors; and/or any other individual.
-Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.
-Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.
-Implement measures to address factors that may lead to abusive situations, for example:
--adequately prepare staff for caregiving responsibilities.
--Instruct staff regarding appropriate ways to address interpersonal conflicts.
--Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.
-Protect residents from any further harm during investigations.
1. Review of Resident #307's facility face sheet showed he/she admitted to the facility 5/10/23 with the following diagnoses:
--Schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly).
--Major depression.
--Atherosclerotic heart disease of native coronary (Damage or disease in the hearts major blood vessels).
Review of Resident #307's admission Minimum Data Set (MDS-a federally mandated assessment tool used by facilities for care planning) dated 5/23/23 showed:
-His/her BIMS (Brief Interview of Mental Status) score was 13 indicating the resident is cognitively intact.
-No behaviors were exhibited during the assessment time frame.
Review of Resident #307's Preadmission Screening and Resident Review (PASSR) dated 5/2/23 showed he/she had an unstable mental condition monitored by a physician or licensed mental health professional at least monthly.
Review of Resident #308's facility face sheet showed:
-admission to the facility on 5/14/23 with diagnoses that include:
--Atherosclerotic heart disease.
--Radiculopathy (a disease of the root of a nerve, such as from a pinched nerve or a tumor).
Review of Resident #308's admission MDS dated [DATE] showed:
-BIMS score of 10, which indicated the resident was moderately cognitively intact.
-No behaviors were exhibited during the assessment time frame.
Review of Resident #308's care plan dated 5/30/23 showed he/she was independent for meeting emotional. intellectual, physical and social needs.
Review of the facility investigation dated 6/1/23 showed:
-On 5/31/23 at approximately 5:40 P.M., Resident #307 confronted his/her roommate Resident #308 in their room.
-Resident #307 wanted $2.00 back from Resident #308 that he/she had lent him/her.
-Resident #308 did not have the money to pay Resident #307.
-Resident #307 attempted to grab Resident #308 around the neck/shoulders.
-Resident #308 used his/her single point cane to hit Resident #307 above his/her left eye causing a small skin tear.
-Staff heard the commotion and entered the room.
-Staff immediately separated the residents preventing further incident from occurring.
During an interview on 6/6/23, at 10:10 A.M., Resident #307 said:
-He/she was not afraid of Resident #308 and never was.
-It was over now and he/she hasn't seen him/her.
-He/she was upset because he/she thought Resident #308 owed him/her $2.00.
Observation on 6/6/23 at 10:10 A.M., showed a small (0.25 inch), laceration above Resident #307's left eye, healing well.
During an interview on 6/6/23 at 10:30 A.M., Resident #308 said:
-Resident #307 jumped on his/her back and started beating him/her.
-He/she had given him/her some salami and he/she offered to pay him/her for it when he/she got the money.
-He/she didn't have the money yet, and the resdient got really mad.
-He/she thinks that Resident #307 stole his/her wallet too.
-He/she was not afraid of the resident at all and he/she hasn't even seen him/her lately.
During an interview on 6/6/23 at 11:00 A.M., the Administrator said:
-These residents haven't really had any behaviors.
-He/she had asked therapy to evaluate Resident #307 for the need of the cane.
-If the resident doesn't need the cane, the facility staff will ask Resident #307 not to use it, as that was what he/she used to hit the roommate.
-He/she believes Resident #308 reacted by hitting Resident #307 with a cane out of frustration and poor impulse control.
During an interview on 6/6/23 at 11:20 A.M., the Director of Nursing (DON) said:
-The facility have not had any issues with Resident #307 before.
-He/she was surprised that this occurred.
-He/she doesn't think that there will be any further issues since the residents now live far away from each other.
2. Review of Resident #55's facility face sheet showed he/she admitted to the facility on [DATE] with diagnoses that include:
--Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles).
--Major Depression.
--Chronic pain.
--Restlessness and agitation.
--Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
--Adjustment disorder (a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after one goes through a stressful life event).
Review of Resident #55's quarterly MDS dated [DATE] showed:
-BIMS score of 15, which indicated that the resident was cognitively intact.
-The resident had no behaviors exhibited during the assessment period.
Review of Resident #55's care plan dated 5/19/23 showed the resident has a psychosocial well-being problem related to ineffective coping by when something does not go the way he/she feels it should go, his/her first instinct is to demand to move rooms; resident has moved rooms multiple times during his/her time at the facility, and will also make false allegations against residents.
Review of Resident #305's facility face sheet showed:
-Resident admitted to the facility on [DATE] with diagnoses that include:
-Schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania).
-Alcohol dependence.
-Chronic Obstructive Pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe).
-Depression.
Review of Resident #305's quarterly MDS, dated [DATE] showed:
-BIMS score of 15.
-The resident had no behaviors exhibited during the assessment period.
Review of Resident #305's care plan dated 3/19/23 showed:
-Resident had a behavior problem of being able to walk steady but demands he/she receives a wheelchair, in the wheelchair he/she rolls at high speeds and does not yield for others related to diagnoses of schizoaffective disorder.
-Resident had potential to be verbally aggressive related to ineffective coping skills, mental/emotional illness, poor impulse control related to schizoaffective disorder.
-Resident had a history of alcohol abuse, he/she yells and cusses at staff and slams doors.
Review of Resident #305's PASSR dated 8/8/22 showed he/she had adjustment disorder, schizoaffective disorder, alcohol abuse, chronic pain and suicidal ideation's.
Review of Resident #309's facility face sheet showed:
-He/she admitted to the facility on [DATE] with diagnoses that include:
--Residual schizophrenia (the third stage of schizophrenia in which the individual experiences fewer or less severe symptoms than those seen in the active stage.
--Major depression.
Review of Resident #309's quarterly MDS dated [DATE] showed:
-BIMS score of 15.
-No behaviors exhibited during the assessment period.
Review of Resident #309's care plan dated 5/23/23 showed:
-The resident had a behavior problem of saying he/she is going to stab him/herself with a fork when he/she is angry related to diagnoses of schizophrenia.
-The resident had a history of calling emergency response for suicidal ideation's. The resident will utilize safety plan made to help with his/her coping skills.
Review of the facility investigation dated 6/2/23 showed:
-Witness to the incident,was Resident #309 who reported:
--He/she was out on the smoke deck with Resident #55 when Resident #305 came out to the smoke deck.
--Resident #305 appeared intoxicated.
--Resident #305 wheeled over to Resident #55 and touched him/her on the leg and the side of his/her breast.
--Resident #55 told Resident #305 not to do that.
--Resident #305 turned towards him/her and demanded a cigarette.
--He/she refused and Resident #305 approached him/her aggressively.
--Staff separated the residents and took Resident #305 to his/her room.
-Resident #55 said that he/she was outside on the smoking deck enjoying a cigarette with his/her friend Resident #309.
-Resident #305 came outside intoxicated and loud.
-The resident wheeled over to the resident and said that he/she liked him/her.
-The resident then tried to touch his/her leg, and touched his/her breast when he/she reached for him/her.
-He/she told the resident to get away.
-Resident #305 then turned to Resident #309 demanding a cigarette.
-Resident #309 refused and Resident #305 approached him/her aggressively.
-Staff came outside and separated the residents and called police.
-He/she called an ambulance because he/she did not want to be near Resident #305.
-Resident #305 admits to touching Resident #55 but states that is because he/she likes him/her.
-Resident #305 said that Resident #55 had kissed him/her earlier.
-Resident denies being the aggressor to Resident #309.
-The nurses put him/her in his/her room to sleep with supervision.
During an interview on 6/6/23 at 11:00 A.M., the Administrator said:
-Resident #305 was reportedly drunk when this incident occurred.
-There have been no reported incidents with the resident before this, so he/she believes it was the alcohol.
-They are considering getting a breathalyzer for the residents, and if they have been drinking, make a plan for monitoring.
During an interview on 6/6/23 at 11:20 A.M., the DON:
-Resident #305 had not had an incident like this before.
-The staff reported to him/her that the resident had been drinking.
-He/she knows that staff instruction were to keep a close eye on him/her.
During an interview on 6/6/23 at 1:10 P.M., Resident #309 said:
-Resident #305 came out on the smoke patio and said to him/her, give me a fucking cigarette.
-Resident #55 said he/she was having chest pains, so he/she helped him/her call 911.
-He/she had never seen Resident #305 act like that.
-He/she does not hang out with him/her, and he/she was obviously drunk.
-He/she was belligerent.
-Resident #305 threw the lit cigarette down and then touched Resident #55's breast.
During an interview on 6/6/23 at 1:30 P.M., Resident #55 said:
-He/she was out on the smoke deck when Resident #305 rolled up and touched his/her breast.
-He/she told Resident #305 to get away from him/her.
-He/she notified the staff what had occurred.
-He/she called the ambulance, because he/she was afraid that the staff wasn't going to call, and he/she was dizzy.
-He/she was never the resident's friend, but never had any issues with him/her before.
3. Review of Resident #306's facility face sheet showed:
-He/she was admitted to the facility on [DATE] with diagnoses that include:
-Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
-Major depression.
Record review of the resident's quarterly MDS dated [DATE] showed:
-His/her BIMS score of 10 which indicatied the resident was moderately cognitively intact.
-Resident showed verbal behavior symptoms during the assessment period.
Review of the resident's care plan dated 4/18/23 showed:
-Resident was independent for meeting emotional, intellectual, physical and social needs.
-Enjoys getting fresh air in the courtyard and smokes.
Review of Resident #305's facility face sheet showed:
-Resident admitted to the facility on [DATE] with diagnoses that include:
-Schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania).
-Alcohol dependence.
-Depression.
Review of the resident's quarterly MDS, dated [DATE] showed:
-His/her BIMS score of 15.
-The resident had no behaviors exhibited during the assessment period.
Review of the facility investigation dated 6/4/23 showed:
-On 6/3/23 Resident #306 and Resident #309 were on the smoke deck.
-Resident #305 came out to the smoke deck.
-Resident #305 asked for a cigarette from Resident #306, and he/she told him/her no.
-Resident #305 attempted to strike Resident #306 barely grazing his/her head.
-Staff who were supervising Resident #305 due to a previous incident immediately intervened and separated the two.
-Police were called and Resident #305 was arrested.
During an interview on 6/6/23 at 11:00 A.M., the Administrator said Resident #305 was not on one to one supervision, but a CNA was assigned to watch the resident closely.
During an interview on 6/6/23 at 3:00 P.M., Resident # 306 said:
-He/she was outside smoking and visiting with Resident #309.
-All of a sudden here comes Resident #305.
-Resident #305 was staring down Resident #309.
-He/she told Resident #305 he/she better stop your shit right now.
-Resident #305 acted all tough.
-Resident #305 got in his/her face and then grazed him/her on the side of the head with his/her hand.
-It did not hurt and it was not hard, but the resident did it.
-He/she feels perfectly safe, and is not afraid of him/her or anyone else here.
-The staff came out pretty quick and got him/her and he/she thinks that the police were called and arrested Resident #305.
-He/she touched Resident #55, then came out and did that to him/her the next day.
-The resident has got to go.
During and interview on 6/6/23 at 3:15 P.M., Resident #309 said:
-Resident #305 grazed Resident #306's head with his/her hand.
-Maybe he/she was still drunk from the night before, he/she did not know.
MO00219411, MO00219326, MO00219462
Apr 2023
21 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 treat the residents with dignity by not ensuring two ...
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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 treat the residents with dignity by not ensuring two sampled residents, (Resident #23 and #72) genitals were covered up during cares and their Foley catheter bags were in a dignity bag when the residents were outside of their rooms out of 21 sampled residents. The facility census was 105 residents.
Record review of the facility's policy, Dignity, dated February 2021 showed:
-Residents were to be treated with dignity and respect at all times.
-Staff was to promote, maintain, and protect residents privacy, including bodily privacy during assistance with personal care and during treatment procedures.
1. Record review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Acquired absence of other parts of urinary tract (surgical removal of part of the urinary system resulting in person having a urostomy tube - a tube that helps you pass urine when your bladder is not working correctly or has been removed).
-Paraplegia (the loss of muscle function in the lower half of your body including the legs).
Record review of the resident's Care Plan dated 12/1/22 showed he/she was dependent on staff for physical needs.
Record review of the resident's 5 day Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 3/28/23 showed:
-The resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 showing he/she was cognitively intact.
-He/she needed the assistance of two staff for physical assistance for bed mobility.
-He/she needed the assistance of two staff to manage his/her ostomy or catheter (tubes from the bladder that run into a collection device to hold the urine) care.
-He/she had a nephrostomy tube (a tube placed in the skin running from the bladder to an outside collection bag to drain the bladder of urine).
-He/she had a medically complex condition.
Record review of the resident's Physician's Order Sheet (POS) dated April 2023 showed staff was to change the urostomy pouch and wafer as needed for leakage, dated 3/27/23.
Observation on 4/17/23 at 9:47 A.M. showed:
-Two Certified Nursing Assistants (CNA)'s were changing the resident.
-The resident's genitals were not kept covered during cares.
-The blinds were not closed on a window which would have allowed the residents on the smoking patio outside of his/her room to see his/her genitals.
-There were two male residents outside of his/her room on the smoking patio.
Observation on 4/17/23 at 12:18 P.M. showed:
-The resident had a Foley bag attached to his/her urostomy tube.
-The resident was wheeling his/her wheelchair down the hall with the Foley bag between his/her feet.
-The Foley bag did not have a dignity bag.
Observation on 4/18/23 at 2:05 P.M. showed:
-The resident was out in the main lobby waiting to talk to the Administrator.
-There were other residents and staff in the main lobby.
-His/her Foley was laying between his/her feet without a dignity bag on the foot pedals of his/her wheelchair.
Observation on 4/19/23 at 10:01 A.M. showed:
-Licensed Practical Nurse (LPN) A and CNA C did cares with the resident.
-The blinds on his/her window to the smoking patio were opened.
-The resident's genitals were exposed for an hour.
-A male resident walked by the resident's room twice on the smoking patio and would have been able to see into the window.
During an interview on 4/19/23 at 10:50 A.M. LPN A said:
-He/she did not realize the blinds in the resident's room were open exposing him/her to anyone who walked by on the smoking patio.
-He/she should have had the blinds or curtain in the resident's room closed during cares.
During an interview on 4/19/23 at 10:55 A.M. CNA C said:
-There had been a sheet hanging on the resident's window the week before.
-He/she thought the blinds did not work on the resident's window.
-They should have closed the blinds during cares so the residents walking by on the smoking patio would not have been able to see the resident's privates.
During an interview on 4/26/23 at 6:00 P.M. the resident said:
-He/she did not like it if the residents outside on the smoking patio could see his/her private area when the staff did cares on him/her.
- He/she could hardly get the staff to come into help him/her much less care about his/her Foley bag being covered up.
2. Record review of Resident #72's Quarterly MDS dated [DATE] showed:
-His/her BIMS score was 13 out of 15 indicating he/she was cognitively intact.
-He/she needed extensive assistance for personal hygiene.
-He/she had a catheter.
Observation on 4/17/23 at 12:40 P.M. showed:
-He/she was going down the hallway in his/her electric wheelchair with the Foley catheter not in a dignity bag.
-He/she passed by two other residents in the hallway.
Observation on 4/21/23 at 10:50 A.M. of cares with LPN A/Wound Nurse and Acting Director of Nursing (DON) showed:
-The two nurses were doing cares with the resident.
-Both nurses left the resident's room for five minutes to obtain additional supplies.
-The nurses left the resident with his/her pants down showing his/her genitals.
During an interview on 4/21/23 at 11:15 A.M. both LPN A and the acting DON said:
-They should not have left the room with the resident exposed.
-They should have at least put a towel over his/her genitals.
During an interview on 4/21/23 at 11:18 A.M. the resident said:
-He/she did not like being left exposed.
-They should have covered him/her up when they left the room.
During an interview on 4/26/23 at 2:02 P.M. LPN B said:
-A Foley catheter bag should be in a dignity bag.
-When doing cares the blinds should be shut for privacy.
-If staff leave a resident's room he/she should be covered up.
During an interview on 4/26/23 at 3:45 P.M. the DON said:
-For dignity the staff should close the curtains to the outside during cares so the residents were not exposed.
-Staff would have been expected to cover up a residents genitals if they left the room.
-A Foley catheter bag should always be in a dignity bag.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers for Medicare and Medicaid Services (CMS) form CMS-10123) was provided to the resident or their representative for one sampled resident (Resident #82) and to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form (CMS)-10055) was provided to the resident or their representative for two sampled residents (Resident #82 and #21) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 105 residents.
Record review of the undated Form Instructions for the NOMNC CMS-10123 form showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end.
Record review of the CMS memo (S&C-09-20), dated 1/9/09, showed:
-The NOMNC, form CMS-10123 is issued when all covered Medicare services end for coverage reasons.
-If the SNF believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of the SNF ABN (form CMS-10055).
-The SNF ABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have.
-If the SNF provides the beneficiary with either the SNF ABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination.
A facility policy was requested but not received.
1. Record review of Resident # 82's SNF Beneficiary Protection Notification Review form completed by the facility during the survey showed:
-The resident's last covered day for Medicare Part A services was 2/9/23.
-The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted.
-A NOMNC was not provided to the resident or representative and it was unknown why the facility did not provide it to the resident.
-A SNF ABN was not provided to the resident or representative and it was unknown why the facility did not provide it to the resident.
2. Record review of Resident #21's SNF Beneficiary Protection Notification Review form completed by the facility during the survey showed:
-The resident's last covered day for Medicare Part A services was 2/23/23.
-The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted.
-A SNF ABN was not provided to the resident or representative and it was unknown why the facility did not provide it to the resident.
During an interview on 4/24/23 at 10:04 A.M., the Social Services Director said:
-He/she could not find Resident #21's SNF ABN or Resident #82's SNF ABN or NOMNC.
-He/she didn't know why they were not done because he/she was not employed at the facility yet when they should have been done.
During an interview on 4/26/23 at 3:44 P.M., the Administrator said:
-The SNF ABN and NOMNC were supposed to be given to the resident or their responsible party 48 hours prior to their discharge from Medicare Part A services.
-Social Services was responsible for providing the notices.
-They have a new Social Services Director.
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
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 provide notification to the Ombudsman (a resident advocate who prov...
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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 notification to the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of the 30-day discharge notices for two sampled residents (Resident #11 and #43) out of 21 sampled residents. The facility census was 105 residents.
Record review of the facility's policy on discharging the resident dated as revised December 2016 showed the policy did not address 30-day discharge notices or notifying the Ombudsman of 30-day discharge notices.
Record review of the facility's undated 30-Day Notice policy showed the policy did not address notifying the Ombudsman of 30-day discharge notices.
1. Record review of Resident #11's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/23/23 showed:
-The resident was cognitively intact.
-The resident ranged from being independent to requiring supervision with all activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting).
-Some of the resident's diagnoses included traumatic brain injury (TBI-brain dysfunction caused by an outside force, usually a violent blow to the head) and seizure disorder (a medical condition that is characterized by episodes of abnormal surges of electrical activity in one's brain leading to a sudden, violent involuntary series of contractions of muscles).
Record review of the resident's Social Service's note dated 2/24/23 showed:
-The resident said he/she wanted to get his/her own apartment and move out of the facility.
-The Social Services Director informed the resident that he/she would assist the resident in locating an apartment.
-The Social Services Director was compiling a list of potential places to where the resident could move.
Record review of the resident's Social Service's note dated 2/27/23 showed the Social Services Director emailed referrals to three facilities.
Record review of the resident's Social Service's note dated 3/9/23 showed the Social Services Director emailed a referral to one additional facility.
Record review of the resident's care plan dated 3/13/23 showed the resident was independent for meeting emotional, intellectual, physical and social needs.
Record review of the resident's Social Service's note dated 3/29/23 showed the Social Services Director gave the resident an application for an apartment on 3/28/23.
Record review of the Social Services Directors note dated 4/4/23 showed the resident was going to be issued a 30-day discharge notice because the resident did not have a medical need to reside in a skilled nursing facility (SNF-a facility that provides inpatient skilled nursing care and related services to individuals who require medical, nursing or rehabilitative services but does not provide the higher level of services available in a hospital) any longer.
Record review of the resident's 30-day notice of discharge date d 4/6/23 showed:
-The resident was being discharged because the resident's health had improved sufficiently so that he/she no longer needed the services provided by the facility.
-The safety of other individuals was endangered.
-The health of other individuals in the facility was endangered.
-The resident was being discharged to a Residential Care Facility (RCF-a residence that provides 24-hour care to adults who are provided with shelter, board and protective oversight but where the individuals do not require as much assistance as other long-term care facilities provide).
Record review of the resident's Social Services Director's note dated 4/6/23 showed:
-The Social Services Director explained to the resident that he/she did not need the SNF level of care any longer.
-The resident was assessed for placement and accepted on 4/5/23 by the Administrator and nurse manager from an RCF.
-The resident was issued a 30-day discharge on that day.
During an interview on 4/18/23 at 2:00 P.M., the resident said:
-He/she received a 30-day notice discharge letter on 4/6/23.
-He/she had not had the time to look for an apartment.
Record review of an email sent to the Department of Health and Senior Services dated 4/21/23 8:38 A.M., showed the Ombudsman wrote that the Administrator told him/her that the resident might be receiving a 30-day discharge notice but he/she did not receive notice when the 30-day discharge was actually issued.
During an interview on 4/25/23 at 10:56 A.M., the Ombudsman said the Administrator told him/her that he/she was considering giving the resident a discharge notice but he/she had not received a copy of the resident's discharge notice.
Documentation that the resident's discharge notice was sent to the Ombudsman was requested from the Administrator but not received.
The resident still resided at the facility upon the exit of the facility's survey on 4/26/23.
2. Record review of Resident #43's quarterly MDS dated [DATE] showed:
-The resident was cognitively intact.
-The resident required limited to extensive assistance with ADLs.
-Some of the resident's diagnoses included a seizure disorder (a medical condition that is characterized by episodes of abnormal surges of electrical activity in one's brain leading to a sudden, violent involuntary series of contractions of muscles), an anxiety disorder (psychiatric disorders that involve extreme fear, worry and nervousness) and depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life).
-The resident had no current plan to discharge from the facility.
-The resident wanted to be asked about returning to the community on all assessments.
Record review of the resident's behavior note dated 4/8/23 showed:
-The resident was observed smoking marijuana on the back smoke patio.
-Education was provided to the resident regarding the use of marijuana.
Record review of the resident's health status note dated 4/14/23 showed:
-Police were called because the resident was suspected of stealing a staff member's debit card.
-Upon the arrival of two police officers, it was found that the resident had a cigarette box with a crack (illegal substance) pipe and crack present as well.
Record review of the resident's notice of 30-day discharge date d 4/15/23 showed:
-The resident would be discharged on 5/15/23.
-The discharge location was a homeless shelter.
-The reasons the resident was being discharged were:
--The safety of other individuals was endangered.
--The health of other individuals in the facility was endangered.
Record review of the Social Services notes dated 4/15/23 showed referrals were sent to eight long-term care facilities for placement.
During an interview on 4/18/23 at 1:02 P.M., the resident said:
-He/she was accused of stealing an employee's credit card.
-He/she got caught with a crack pipe.
-He/she received a 30-day discharge letter two days ago.
-He/she was planning on going to a facility where his/her boyfriend/girlfriend was going.
Record review of the Social Services note dated 4/18/23 showed three of the facilities that were sent referrals declined to accept the resident.
Record review of an email sent to the Department of Health and Senior Services dated 4/21/23 8:38 A.M., showed the Ombudsman wrote he/she was not aware of the resident receiving a 30-day discharge notice.
During an interview on 4/25/23 at 10:56 A.M., the Ombudsman said he/she was not notified of the resident's receipt of a 30-day discharge notice.
During an interview on 4/25/23 at 1:00 P.M., the Social Services Director said:
-A Certified Nursing Assistant (CNA) accidentally left his/her jacket in the resident's room a couple of weeks ago.
-When the CNA went back to get his/her jacket, his/her bank card was missing.
-The resident denied taking the bank card.
-The police were called.
-The CNA put a hold on his/her bank card.
-While the police were there, they found a crack pipe in the resident's room.
-The resident had also been caught smoking pot.
-He/she was helping the resident find a place to live.
-Some of the facilities he/she sent referrals to did not accept the resident.
-There was one facility who was considering taking the resident but he/she had to find some paperwork to send to the other facility before they would accept him/her.
-He/she believed he/she would find the resident a place to live.
-The facility that was interested in accepting the resident probably wouldn't take the resident's boyfriend/girlfriend.
-The resident wants to go wherever his/her boyfriend/girlfriend goes.
Documentation that the resident's discharge notice was sent to the ombudsman was requested from the Administrator but not received.
The resident still resided at the facility upon the exit of the facility's survey on 4/26/23.
3. During an interview on 4/26/23 at 12:50 P.M., the Social Services Director said:
-His/her first day at the facility was 2/23/23.
-The Administrator was the one who had been sending the list of residents who were given discharge notices to the Ombudsman.
During an interview on 4/26/23 at 3:44 P.M., the Administrator said:
-The Social Worker was responsible for providing the discharge list to the Ombudsman.
-The current Social Worker was new to the facility.
-He/she sends the 30-day discharge notices immediately to the Ombudsman.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (do...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (document that specified health care and support needs and outlines how the facility met resident requirements) that included needs, goals, outcomes and preferences for one sampled resident (Resident #26) for use of oxygen and one sampled resident (Resident #44) for bowel and bladder routine out of 21 sampled residents. This practice had the potential to effect all residents. The facility census was 105 residents.
Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated, March 2022, showed:
-A comprehensive, Person Centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident.
-The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident.
-The comprehensive, person-centered care plan was developed within seven days of the completion of the required Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and more than 21 days after admission.
-The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment.-Each resident's comprehensive person-centered care plans was consistent with the resident's rights to participate in the development and implementation of his/her care plan, including the right to:
--Participate in the planning process.
--Identify individuals or roles to be included.
--Request meetings.
--Request revisions to the care plan.
--Participate in establishing the expected goals and outcomes of care.
--Receive the services and/or items included in the plan of care.
--See the care plan and sign it after significant changes were made.
-The resident was informed of his/her right to participate in his/her treatment and provide advance notice of care planning conferences.
-If the participation of the resident and his/her resident representative in developing the resident's care plan was determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.
-The comprehensive, person-centered care plan included:
--Measurable objectives and time frames.
--Descriptions of the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, including:
---Services that would otherwise be provided for the above, but were not provided due to the resident exercising his/her right to refuse treatment.
---Any specialized services to be provided as a result of the Preadmission Screening and Resident Review (PASRR- a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source; this includes dually certified beds both Medicare and Medicaid) recommendations.
---Which professional services were responsible for each element of care.
--Included the resident's stated goals upon admission and desired outcomes.
--Builds on the resident's strengths.
--Reflects currently recognized standards of practice for problem areas and conditions.
-Services provided for or arranged by facility and outlined in the care plan were:
--Provided by qualified persons.
--Culturally competent.
--Trauma-informed.
Care plan interventions were chosen only after data gathered, events were properly sequenced, considered resident problem areas and their causes as well as relevant clinical decision making.
-When possible, interventions addressed the underlying sources of the problem areas, not just symptoms or triggers.
-Assessments of residents were ongoing and care plans were revised as information about the resident and resident's condition changed.
The IDT reviewed and updated care plans when:
--There was a significant change in the resident's condition.
--The desired outcome was not met.
--The resident was readmitted to the facility from a hospital stay.
--On a quarterly basis in conjunction with the required quarterly MDS assessment.
-The resident had the right to refuse to participate in the development of his/her are plan and medical nursing treatments. Such refusals were documented in the resident's clinical record in accordance with established policies.
1. Record review of Resident #26's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/22/23, showed:
-The resident was admitted to the facility on [DATE].
-The resident scored a 13 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions).
--This showed the resident was cognitively intact.
Record review of the resident's Treatment Administration Record (TAR), dated March 2023, showed the resident received two liters of oxygen per nasal cannula every 24 hours as needed for shortness of breath dated 3/14/23.
Record review of the resident's care plan, dated 3/28/23, showed the resident had no focus areas, interventions or goals related to oxygen use.
Record review of the resident's Physician Order Summary (POS) dated 4/24/23, showed:
-The resident had active orders for oxygen at two liters per nasal cannula every 24 hours as needed for shortness of breath.
-The resident was diagnosed with chronic hepatitis C (infection of the blood causing chronic liver disease), osteomyelitis (inflammation of bone or bone marrow usually due to infection, and obesity (being overweight).
2. Record review of Resident #44's Annual MDS, dated [DATE], showed:
-The resident scored a 15 on the BIMS.
--This showed the resident was cognitively intact.
-The resident's diagnoses included: neurogenic bladder (a lack bladder control due to a brain, spinal cord or nerve problem), and multiple sclerosis (a chronic and progressive disease involving damage to nerve cells in the brain and spinal cord).
Record review of the resident's Functional Status section of the annual MDS, dated [DATE], showed the resident required extensive assistance with toilet use by staff providing weight-bearing support.
Record review of the resident's care plan, dated 4/8/23, showed there were no focus areas, goals or interventions addressing the resident's bowel and bladder needs.
3. During an interview on 4/20/23 at 9:31 A.M., Certified Nurse Assistant (CNA) A said the nurses were in charge of care plans.
During an interview on 4/21/23 at 5:41 A.M., CNA B said the nurses are the one who do the care plans.
During an interview on 4/24/23 at 12:12 P.M., RN A said:
-Oxygen use should be in the care plan.
-The MDS Coordinator takes care of updating the care plans.
-Resident's with bowel and bladder issues should have those care planned.
During an interview on 4/26/23 at 3:47 P.M., the Director of Nursing (DON) said:
-The need for a resident to have oxygen should be part of the resident's care plan.
-Resident's with incontinence issues should have that care planned.
-Nursing was responsible for ensuring the care plan was up to date and correct.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #88's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis:...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #88's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis:
-Type 2 Diabetes.
Record review of the resident's care plan dated 8/16/22 showed:
-He/she had diabetes and was on insulin.
-Staff was to administer diabetes medication as ordered by the physician.
-Staff was to monitor and document for side effects and effectiveness.
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 4/2/23 showed:
-His/her Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating he she was moderately cognitively impaired.
-He/she had diabetes.
Record review of the resident's POS dated April 2023 showed the following order dated 6/25/22:
-Novolog Solution (a rapid acting insulin that helps to lower mealtime blood sugar spikes) inject as per sliding scale;
--150 to 200 (give) two units.
--201 to 250 (give) four units.
--251 to 300 (give) six units.
--351 to 449 (give) 10 units.
--450 to 451 (give) 12 units.
--Administer subcutaneous (administered under the skin) before meals related to type 2 diabetes.
-There was no order how often staff was to check the resident's blood sugar.
-There was no order when to call the physician with a too high or too low blood sugar.
-There was no order what staff was to do for a too low blood sugar.
During an interview on 4/24/23 at 9:24 A.M. the resident's Physician said:
-He/she did not see an order to check the resident's blood sugar or parameters of when staff should notify him/her with too high or too low blood sugars.
-The Director of Nursing (DON) was responsible to ensure orders were complete.
3. During an interview on 4/26/23 at 10:22 A.M., Registered Nurse (RN) A said the nurse should obtain parameters on when to call the physician and what to do when the resident's blood glucose levels were too high or too low.
During an interview on 4/26/23 at 2:02 P.M. Licensed Practical Nurse (LPN) B said:
-There should have been an order for an accu check for the resident if they were a Diabetic on insulin.
-He/she did not know what the parameters were for calling the physician if a resident's blood sugar was too high or too low.
-The DON was to ensure physician's orders were completed.
During an interview on 4/26/23 at 3:45 P.M. the Acting DON said:
-Diabetic residents should have an order for accu checks.
-There should have been orders for when to call the physician for too high and too low blood glucose levels.
-There should have been parameters for what should been done for low blood sugars such as glucophage (medication used to quickly raise a blood sugar in a persons too low blood sugar).
During an interview on 4/26/23 at 3:45 P.M., the Administrator and the MDS Coordinator said:
-Generally the nurse should call the physician if blood glucose levels were below 60 or above 400.
-The nurse should obtain parameters and should call for clarification when accucheck orders don't include parameters on when to call the physician.
Based on observation, interview, and record review, the facility failed to ensure there were written parameters for when the staff should notify the physician and what to do when a resident's blood sugar was too high or too low for two sampled residents, (Resident #35 and Resident #88) out of 21 sampled residents. The facility census was 105 residents.
Record review of the facility's policy, Nursing Care of the Older Adult with Diabetes Mellitus (diabetes - a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), dated November 2020 showed:
-Use a glucometer (a small device that measures how much sugar is in a person's blood sample) for capillary blood sampling to measure correct blood glucose levels.
-The target range for healthy older adults was considered 90 - 130 milligrams (mg)/deciliter (dl) (fasting - a person who has not eaten overnight).
-The provider would order the frequency of glucose monitoring and establish appropriate glycemic (how quickly and how high foods increase in blood glucose levels) targets for the individual residents.
-Manage hypoglycemia (low blood sugar) according to protocols and provider orders.
-Establish provider notification protocols, for example:
-Call provider immediately if the resident was hypoglycemic less than 70 mg/dl.
-Call as soon as possible when;
-Blood glucose values were regularly 70 - 100 mg/dl for possible regimen adjustment.
-Blood glucose values were greater than 250 mg/dl more than one within a 24 hour period.
-Blood glucose values were greater than 300 mg/dl more than once over two consecutive days.
-Blood glucose reading was too high for the glucometer.
-The resident was vomiting, has symptomatic hyperglycemia (high blood sugar level) or poor oral intake.
-Follow the provider orders for blood glucose monitoring.
-For the resident receiving insulin (a hormone that helps your body turn food into energy and controls your blood sugar levels) which was well controlled;
-Monitor blood glucose levels twice a day if on insulin.
-Monitor three to four times a day in on intensive insulin therapy or sliding-scale insulin (varies the dose of insulin based on blood sugar level).
1. Record review of Resident #35's care plan dated 4/3/22 showed:
-The resident had a diagnosis of diabetes.
-The resident was non-insulin dependent.
-The interventions did not include monitoring blood glucose levels.
Record review of the resident's Treatment Administration Record (TAR) dated March 2023 showed:
-A physician's order dated 2/14/22 to check the resident's blood glucose one time a day every Monday, Wednesday and Friday related to diabetes.
-The resident's blood glucose results varied from a low of 122 to a high of 407.
Record review of the resident's Physician's Order Sheet (POS) dated April 2023 showed:
-A physician's order dated 2/14/22 to check the resident's blood glucose one time a day every Monday, Wednesday and Friday related to diabetes.
-There was no order when to call the physician when the resident's blood glucose was too high or too low.
-There was no order what staff was to do when the resident's blood glucose was too high or too low.
Record review of the resident's TAR dated April 2023 showed:
-A physician's order dated 2/14/22 to check the resident's blood glucose one time a day every Monday, Wednesday and Friday related to diabetes.
-The resident's blood glucose results varied from a low of 98 to a high of 185.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 have in place measures to effectively communicate wit...
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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 have in place measures to effectively communicate with one sampled resident (Resident #88) whom English was not his/her primary language and did not provide activities for him/her in Spanish (his/her primary language) out of 21 sampled residents. The facility census was 105 residents.
Record review of the facility's policy, Translation and /or Interpretation of Facility Services dated November 2020 showed:
-The facility's language access program would ensure that individuals with Limited English Proficiency (LEP) shall have meaningful access to information and services provided by the facility.
-When encountering LEP individuals, staff members would conduct the initial language assessment (e.g., I speak Cards and notify the staff person in charge of the language access program.
-Written translation of vital information was available in the following languages at this time:
-Policy was blank.
-Vital information included the following:
--Eligibility for services or benefits (including language access).
--admission information.
--Advance directives.
--Resident rights.
--Authorization for use or disclosure of protected health information.
--Consent for treatment.
1. Record review of Resident #88's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Diabetes (a group of diseases that result in too much blood sugar in the blood).
-Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).
-Acute pain.
-Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act).
-The resident was his/her own responsible party.
Record review of the resident's care plan dated 3/29/23 showed:
-He/she had little or no activity involvement related to depression.
-Staff was to establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary, dated 12/22/22.
-He/she needed reminders and encouragement from staff to come to activities or at least a change of scenery from his/her room, dated 1/21/23.
-He/she refused the church and the 1:1 visits and bible study, dated 1/21/23.
-He/she had a communication problem related to he/she spoke Spanish and knew very little English.
-Staff were to monitor the effectiveness of communication strategies and assistive devices English/Spanish communication board, dated 3/29/23.
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) date 4/2/23 showed his/her Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating he/she was moderately cognitively impaired.
Observation on 4/17/23 at 1:45 P.M. showed:
-There was no communication device in the resident's room.
-There was no phone number for a translator in his/her room or at the Nurses' station.
-The resident was watching Spanish TV.
During an interview on 4/17/23 at 1:45 P.M. the resident said:
-NOTE: The surveyor used a Spanish/English translation application (app) on the surveyor's private phone.
-He/she was not able to state his/her name when asked.
-He/she mainly sat and watched TV in his/her room.
During an interview on 4/19/23 Licensed Practical Nurse (LPN) A said:
-The resident was from [NAME].
-The resident only spoke Spanish.
-Some of the staff could speak Spanish to the resident.
-Some of the staff would use their personal phones with a translator app on it.
-There was not always someone working who could translate if the resident had a need.
-Sometimes they had to call family to translate.
-He/she did not know if the facility had a translation phone available.
-He/she had not seen a translation/communication board in the resident's room.
Record review of the resident's face sheet showed:
-His/her emergency contact #1 was listed.
-His/her emergency contact #2 was listed.
During a family interview on 4/20/23 at 2:00 P.M. the resident's emergency contact #1 said:
-He/she only spoke Spanish.
-You call emergency contact #2, no understand.
During a family interview on 4/20/23 at 2:00 P.M. emergency contact #2 said:
-He/she spoke broken English.
-Family lived out of state and were not able to visit the resident.
-Emergency contact #1 talked to the resident on the phone in Spanish.
-Emergency contact #1 would not be able to understand what the facility would tell him/her in English.
During an interview on 4/20/23 at 3 P.M. the acting Director of Nursing (DON) said:
-A Urinalysis (UA - test for infections in the urine) was not done as the resident had a communication issue related to he/she did not speak English, he/she only spoke Spanish.
-The resident thought they wanted a blood draw not a urine sample.
-It was not done due to the language barrier.
During an interview on 4/21/23 at 9:00 A.M. Certified Nursing Assistant (CNA) D said:
-The facility had a translator phone in someone's office.
-Probably would not be able to use it after office hours.
-There was no number to call for the translator that he/she knew of.
-There was no translator board to communicate in the resident's room that he/she knew of.
-There was not always a staff member to help translate to the resident.
During an interview on 4/21/23 at 2:00 P.M. the resident said (through a Spanish speaking staff member) he/she had not had a communication board until yesterday.
During an interview on 4/24/23 at 9:24 A.M. the resident's Physician said:
-He/she had not been notified by staff that they were not able to obtain the UA for the resident as ordered.
-He/she has a translator app on his/her cell phone to speak to the resident in Spanish.
During an interview on 4/26/23 at 2:02 P.M. Licensed Practical Nurse (LPN) B said:
-He/she had not seen any activities done with the Spanish speaking residents.
-There were three residents that English was not their first language.
-It was hard to communicate with the resident as he/she hardly spoke any English.
-There was a Spanish speaking housekeeper that he/she used to translate if he/she needed something from the resident.
-He/she was not sure the housekeeper would have been able to translate medical terms.
-The resident did not have a translator board in his/her room until the other day.
-He/she did not know about a phone number for a translator line.
-There should have been a communication board in his/her room.
-There should have been a phone number at the Nurse's station to call for a translator.
During an interview on 4/26/23 at 3:00 P.M. the Activity Director said:
-He/she had tried to get the resident to go to the church services but he/she was not interested.
-The resident had Spanish speaking TV and mostly sat in his/her room and watched TV.
-It was hard to work through an interpreter to find out what the resident's likes were.
-There were three residents who spoke Spanish as their first language, the other two could speak some English.
-There should have been an assessment done when the resident first came to find out what he/she liked to do.
-He/she has been here a year.
-The resident had been here a year.
-He/she had not done any activities with the resident.
During an interview on 4/26/23 at 3:45 P.M. the acting Director of Nursing said:
-During morning rounds by Administrative team the resident should have been observed for activities.
-The resident had a Spanish bible.
-There was a group from the church who came in that spoke Spanish.
-The resident did not go to the church services.
-The resident watched Spanish TV in his/her room.
-He/she liked his/her mail translated.
-The staff would help him/her with his/her mail.
-The Activities Director should have made an activity inventory upon admission.
-The resident could do crossword or word search in Spanish.
-He/she was not sure if any Spanish food was served to the three Spanish speaking residents, maybe tacos.
-The Activities Director should have found something for him/her to do.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Urinalysis (a test of your urine to check for infection,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Urinalysis (a test of your urine to check for infection, kidney problems, or diabetes) after a physician ordered the test for one sampled resident (Resident #88) out of 21 sampled residents. The facility census was 105 residents.
Record review of the facility's policy, Principles of Laboratory Specimen Collection, dated 4/1/22 showed:
-A specimen collection was performed as ordered by a physician.
-Contact the Unit Supervisor for questions or concerns regarding specimen collection.
-Document in the progress notes any abnormalities associated with the collection process.
1. Record review of Resident #88's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Diabetes (a group of diseases that result in too much sugar in the blood).
-Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 4/2/23 showed:
-His/her Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating he/she was moderately cognitively impaired.
-He/she needed the assistance of one staff member to use the toilet.
-He/she was occasionally incontinent of urine.
Record review of the resident's care plan dated 8/16/22 showed:
-He/she had a self care performance deficit related to generalized weakness, Dementia, Diabetes, and used a wheelchair for locomotion.
-He/she required the assistance of one staff member to use the toilet.
-He/she had impaired cognitive function related to Alzheimer's.
-Staff was to ask yes or no questions.
Record review of the resident's care plan dated 3/29/23 showed:
-He/she had a communication problem related to the resident spoke Spanish and knew very little English.
-Staff was to use communication tools as needed.
Record review of the resident's Physician's Order Sheet dated April 2023 showed a physician order for a Urinalysis (UA), dated 2/8/23.
Record review of the resident's medical record showed:
-There was no documentation of a result from the urinalysis.
-There was no documentation the lab was collected.
-There was no documentation the Physician was notified the lab was not collected.
During an interview on 4/18/23 at 12:02 P.M. the Physician said:
-He/she expected the staff to follow Physician's orders.
-If they could not follow the orders he/she should have been notified.
During an interview on 4/20/23 at 10:00 A.M. the acting Director of Nursing (DON) said:
-The resident had been having urinary problems.
-There was a physician's order for a UA on 2/8/23.
-Because of the language barrier the resident thought the lab was to draw blood not take a urine sample.
-It should have been passed on to the next shift to obtain the UA if the day shift was not able to obtain it.
-He/she was not sure if the sample was ever obtained.
-There was no documentation the UA was obtained.
-There was no result for the lab so it was not done.
-The physician was not aware the lab was not obtained.
-The resident had an order on 4/11/23 to see a Urologist.
-He/she has made several phone calls to the Urologist but as of today the resident does not have an appointment.
-There was no documentation of the attempts to obtain an appointment for the urologist for the resident.
-Attempts should have been documented in the resident's chart.
-The physician was not aware that he/she was having an issue obtaining an appointment for the resident.
-It usually only takes a phone call to get a physician appointment.
-He/she did not know why it was taking so long to get an appointment.
During an interview on 4/21/23 at 2:00 P.M. the DON said he/she was able to get an appointment for the resident to see a Urologist.
During an interview on 4/24/23 at 9:24 A.M. the Physician said:
-The resident had an order for a UA on 2/8/23.
-It wasn't done.
-He/she would have expected to have been notified that the UA was not done.
-He/she had not been notified the lab sample was not done.
-Nursing was responsible for ensuring labs were done.
-Nursing was responsible to ensure the appointments were made for the residents within a day or two.
-The appointment might be several weeks away but to have it scheduled at the very latest within the week the order was written.
-There needs to be a better system to ensure labs have been drawn and appointments were made.
During an interview on 4/26/23 at 2:02 P.M. Licensed Practical Nurse (LPN) B said:
-An order from the physician should have been carried out within 24 hours unless it was emergent.
-If staff was not able to obtain the lab within 24 hours the physician should have been notified.
During an interview on 4/26/23 at 3:45 P.M. the acting DON said:
-The nurse should have ensured the UA was obtained.
-After 24 hours if the UA was not collected the Physician should have been notified.
-Notifying the physician should have been documented.
-Their computer system communicates with the physician.
-The DON should have monitored lab orders to ensure they had been completed.
-There currently is not a system in place to ensure orders had been completed.
-A physician's appointment should have been scheduled within five days or the physician should have been notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and the oxygen humidifier were s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and the oxygen humidifier were stored in a sanitary condition; and to change out the oxygen tubing per physicians' order for two sampled residents (Resident #18 and #64) out of 21 sampled residents. The facility census was 105 residents.
Record review of the facility's policy, Oxygen Administration, dated 2022 showed:
-Change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.
-Change humidifier bottle when empty, every 72 hours, or per facility policy, or as recommended by the manufacturer.
-Use only sterile water for humidification.
-Change nebulizer tubing and delivery device every 72 hours or per facility policy and as needed if they become soiled or contaminated.
-Keep delivery devices covered in plastic bag when not in use.
1. Record review of Resident #18's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation (a group of lung diseases that block airflow and make it difficult to breathe.
-Obstructive sleep apnea (a breathing disorder characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep).
-Acute and Chronic Respiratory Failure with Hypercapnia (a condition in which you do not have enough oxygen in the tissues in your body or there is too much carbon dioxide in your blood).
Record review of the resident's care plan dated 2/27/23 showed:
-He/she had COPD.
-He/she had altered respiratory status/difficulty breathing related to sleep apnea.
-He/she was on two liters of oxygen per nasal cannula (rubber tubing that delivers oxygen to a person's nose).
-Staff was to follow CPAP orders.
Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 3/23/23 showed:
-He/she needed extensive physical assistance for hygiene.
-He/she was short of breath when laying flat.
-He/she was on oxygen therapy.
-His/her Brief Interview for Mental Status (BIMS) score was 7 indicating he/she was severely cognitively impaired.
Record review of the resident's Physicians' Order Sheet (POS) dated April 2023 showed the following orders:
-Change oxygen tubing weekly and as needed every night shift on Sundays related to COPD, dated 2/24/23.
-Continuous Positive Airway Pressure (CPAP a form of positive airway pressure ventilation applied to the upper respiratory tract of a person) on when sleeping every night shift for sleep apnea, dated 2/24/23.
-Oxygen at two liters via nasal cannula continuous, dated 3/14/23.
Observation on 4/17/23 at 10:06 A.M. showed:
-The resident was wearing the oxygen.
-The oxygen tubing was touching the floor by the resident's bed.
-The oxygen tubing was not dated.
Observation on 4/17/23 at 1:51 P.M. showed:
-The resident was wearing the oxygen.
-The oxygen tubing was touching the floor by the resident's bed.
-The oxygen tubing was not dated.
During an interview on 4/17/23 at 1:55 P.M. the resident said the staff changes the tubing out every few weeks.
Observation on 4/24/23 at 10:24 A.M. showed:
-The oxygen tubing was dated 4/16/23.
-The oxygen tubing was touching the floor by the resident's bed.
-NOTE: The oxygen tubing was not dated 4/16/23 when it was observed on 4/17/23.
During an interview on 4/24/23 at 10:25 A.M. the resident said they have not changed the tubing for a couple of weeks.
2. Record review of Resident #64's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Acute respiratory failure with hypercapnia.
-Asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe).
-Lobar pneumonia (bacteria in one part of your lungs).
-Obstructive sleep apnea.
Record review of the resident's Annual MDS dated [DATE] showed:
-His/her BIMS score was 15 out of 15 indicating he/she was cognitively intact.
-He/she was a two person assist for bed mobility.
-He/she had shortness of breath with laying flat.
-He/she was on oxygen therapy.
Record review of the resident's care plan dated 1/25/23 showed:
-The resident was on oxygen therapy.
-Staff was to encourage the resident to wear his/her Bilevel Positive Airway Pressure (Bi-PAP a device that helps with breathing) as ordered.
-Oxygen at 2 liters via nasal prongs/mask as ordered.
Record review of the resident's POS dated April 2023 showed the following order for a Bi-PAP on with two liters per minute of oxygen when sleeping two times a day for sleep apnea (temporary cessation of breathing, especially during sleep).
Observation on 4/17/23 at 1:35 P.M. showed:
-The resident's Bi-PAP tubing and mask were hanging off of a dirty Intravenous (IV) pole.
-The pole appeared to have tube feeding that had dripped down.
-The pole was rusty.
-The Bi-PAP mask was discolored with a light brown color.
-The Bi-PAP mask was not in a bag.
-There was no date on the Bi-PAP mask or tubing.
-The oxygen concentrator (machine that makes oxygen) had a humidifier (a container with water that oxygen flows through so that a persons nose does not dry out) bottle sitting on it.
-There was no date on the humidifier bottle.
-The resident was wearing oxygen at two liters per nasal cannula.
Observation on 4/18/23 at 9:00 A.M. showed:
-The Bi-PAP tubing and mask were hanging off of a dirty IV pole.
-The Bi-PAP tubing and mask were not in bag.
-There was no date on the humidifier bottle.
-There was no date on the Bi-PAP mask or oxygen tubing.
-The resident was wearing oxygen at two liters per nasal cannula.
Observation on 4/20/23 at 11:00 A.M. showed:
-The Bi-PAP tubing and mask were hanging off of a dirty IV pole.
-The Bi-PAP tubing and mask were not in bag.
-There was no date on the humidifier bottle.
-There was no date on the Bi-PAP mask or oxygen tubing.
-The resident was wearing oxygen at two liters per nasal cannula.
Observation on 4/24/23 at 10:26 A.M. showed:
-The Bi-PAP tubing was dated 4/16/23.
-The Bi-PAP mask was hanging off of the dirty IV pole.
-The Bi-PAP mask was not in a bag.
-The humidifier bottle was sitting on the floor.
-The humidifier bottle did not have a date on it.
-The resident was wearing oxygen at two liters per nasal cannula.
-NOTE: The Bi-PAP tubing was not dated 4/16/23 when observed on 4/17/23, 4/18/23, and 4/20/23.
3. During an interview on 4/24/23 at 10:30 A.M. Certified Nursing Assistant (CNA) H said:
-He/she did not change the oxygen tubing unless it was dirty.
-He/she had not seen any date or initials on the oxygen tubing or mask.
-He/she did not know if there was a scheduled date to change the oxygen tubing or mask.
-He/she did not know when they were supposed to change the water in the humidifier.
-He/she had just put tap water in the humidifier if it was low.
-The humidifier should not be on the floor.
-He/she did not pick up the humidifier off of the floor or change it out.
-He/she did not think staff needed to initial or date if they changed the oxygen tubing/mask or add water to the humidifier.
During an interview on 4/24/23 at 12:30 P.M. Licensed Practical Nurse (LPN) C said:
-Resident #64 wore his/her Bi-PAP mask at night.
-The mask should be in a bag with the date it was changed when it was not being worn.
-The mask should not be on a dirty IV pole.
-Oxygen tubing should be changed weekly, initialed and dated.
-The humidifier bottle should also be dated when it was changed.
-The humidifier bottle should not have been on the floor.
-The humidifier bottle should be filled with distilled water not tap water from the resident's sink.
During an interview on 4/25/23 at 12:00 P.M. LPN C said:
-There should have been a physician's order for Resident #64 to be on oxygen.
-He/she was on oxygen at 2 liters per nasal cannula.
-The nurses should have seen that there was no order for the oxygen and obtained one from the physician.
-Ultimately the Director of Nursing (DON) would have been responsible to ensure the POS was correct.
During an interview on 4/26/23 at 2:02 P.M. LPN B said:
-Oxygen tubing should be changed every day or two.
-Staff should follow the physician's order to change it.
-Resident #64 should have had an order for oxygen as he/she wore it all the time.
-Staff should document when they changed the tubing in the nurses' notes or on the Treatment Administration Record.
-Oxygen tubing should not touch the floor.
-When not in use the oxygen tubing/mask should be in a clear bag and dated when it had been changed.
-The oxygen humidifier bottle should not be on the floor, it should be in a container on the concentrator.
-Staff should have used distilled water in the humidifier and dated the container when it was changed.
During an interview on 4/26/23 at 3:45 P.M. the acting DON said:
-Oxygen tubing or an oxygen mask should be stored in a bag when not in use.
-The date the tubing was changed should have been written on the bag with a permanent marker.
-Oxygen tubing should not be on the floor.
-The oxygen humidifier bottle should not have been on the floor.
-The humidifier bottle should be attached to the concentrator.
-The Nurse or CNA should change the tubing, mask, and humidifier bottle weekly.
-The humidifier bottle should be filled with distilled water.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor for side effects of psychotropic (a type of psychiatric med...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor for side effects of psychotropic (a type of psychiatric medication which was available on prescription to treat psychosis) medications for one sampled resident (Resident #26) out of 21 sampled residents. The facility census was 105 residents.
Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy, dated April, 2018, showed:
-The physician and staff will identify situations in which a resident took medications associated with potentially significant medication-related problems such as allergies, drug to drug interactions drug-food interactions and adverse drug reactions.
-The physician and staff will identify significant factors that may affect medication effectiveness and medication -related problems.
-The staff and physician will identify and address unexpected, unintended, undesirable or excessive responses to medication based on the severity of underlying conditions, the seriousness of any adverse drug reactions, risks or worsening medical conditions and other factors,
-The staff and physician will monitor the progress of anyone with a probable adverse drug reaction and anyone for whom medications have been adjusted.
1. Record review of Resident #26's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/22/23, showed:
-The resident was admitted to the facility on [DATE].
-The resident scored a 13 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions).
--This showed the resident was cognitively intact.
Record review of the resident's Physician Order Summary (POS) dated 4/24/23, showed:
-The resident was diagnosed with Major Depressive Disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable).
-The resident was ordered Clonazepam (drug used for the acute management of the panic disorder) oral tablet, one milligram (mg) by mouth every eight hours as needed for Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
-Start date 3/9/23.
Record review of the resident's Treatment Administration Record (TAR) dated March 2023 showed:
-The resident received Clonazepam on March 21, and 23-27.
-Nowhere on the TAR showed the resident was monitored for side effects of Clonazepam.
Record review of the resident's TAR dated April 2023 showed:
-The resident received Clonazepam on April 4, 6, 8-10, 13-17, 21, and 23-26.
-Nowhere on the TAR showed the resident was monitored for side effects of Clonazepam.
During an interview on 4/26/23 at 3:47 PM, the Director of Nursing (DON) said:
-He/she would expect to see monitoring of the side effects of Clonazepam on the MAR/TAR.
-Nursing was responsible for ensuring the TAR was correct.
-Nursing was responsible for monitoring for medication side effects and documenting on the TAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
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 obtain physician ordered labs and/or maintain lab results for two s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain physician ordered labs and/or maintain lab results for two sampled residents (Resident #12 and #35) out of 21 sampled residents. The facility census was 105 residents.
A policy regarding following physician's orders for labs was requested but not received.
During an interview on 44/26/23 at 2:27 P.M., the Administrator said if a policy wasn't provided that was requested that they did not have it or it was in the computer and they did not find it.
1. Record review of Resident #12's care plan for the admission date of 2/7/22 showed the resident had a diagnosis of Convulsions (a hyperexcitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of muscles).
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/25/23 showed the following staff assessment of the resident:
-Had short and long-term memory impairment.
-Had a diagnosis of a Seizure disorder (a medical condition that is characterized by episodes of abnormal surges of electrical activity in one's brain leading to a sudden, violent involuntary series of contractions of muscles).
Record review of the resident's Physician's Order Sheet (POS) dated April 2023 showed:
-A physician's order dated 2/7/22 for Valproate Sodium Solution (anticonvulsant medication used to control certain types of seizures) 250 milligrams (mg)/5 milliliter (ml), give 750 mg three times a day for Convulsions.
-A physician's order dated 2/28/22 for a Valproic Acid level (VPA-used to measure the amount of Valproic Acid (a medication used to decrease symptoms of epilepsy or of a mood disorder) in the blood to determine whether the drug concentration is within therapeutic range) every three months.
Record review of the resident's medical records showed no VPA lab results.
2. Record review of Resident #35's care plan for the admission date of 4/3/22 showed the resident had a diagnosis of Diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:
-Cognitively intact.
-Had a diagnosis of Diabetes.
Record review of the resident's POS dated April 2023 showed physician's orders dated 2/13/22 for:
-Comprehensive Metabolic Panel (CMP - a panel of labs that give information regarding the functioning of one's kidney, liver, electrolytes (Measures electrolytes such as levels of sodium, the body's main electrolytes, which helps control the amount of fluid in the body and helps nerves and muscles work properly. Chloride also helps control the amount of fluid in the body), acid/base balance (Having the right amount of acid and base in the blood and other body fluids. The body uses different mechanisms to control the blood's acid-base balance including the kidneys and lungs) and blood sugar (measures the amount of sugar in one's blood and helps diagnose diabetes) and blood protein levels (Measures the amount of protein in one's blood which are important for the health and growth of the body's cells and tissues and can help diagnose several health conditions, including kidney and liver disease)).
-Complete Blood Count (CBC- a test that gives information about blood cells).
-HgbA1C (a hemoglobin test used to monitor diabetes).
-Lipid profile (a blood test to assess liver function).
--All to be drawn every six months.
Record review of the resident's medical records showed the only lab result was the resident's HgbA1C on 8/19/22 which was high at 7.7 (4-6 normal range).
3. During an interview on 4/24/23 at 9:24 A.M., the Medical Director said:
-The facility was not good about ensuring that labs were done.
-He/she had a hard time getting lab results.
During an interview on 4/26/23 at 10:24 A.M., Registered Nurse (RN) A said:
-Lab orders were entered by the nurses.
-The nurses entered a frequency if it was a repeating lab and it would automatically generate the lab frequency.
-The charge nurse working when lab results come in was responsible for contacting the doctor.
During an interview on 4/26/23 at 3:44 P.M. the acting Director of Nursing (DON) said:
-Labs should have been done as ordered.
-They did not have a system for tracking labs to make sure they were done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR a fede...
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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 Preadmission Screening and Resident Review (PASRR a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) was completed and available for three sampled residents (Resident #79, #18, #64 ) out of 21 sampled residents. The facility census was 105 residents.
The facility s PASRR Policy was requested several times and one was not provided by time of exit.
1. Record review of resident #79's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/20/23, showed:
-The resident was admitted to the facility on [DATE].
-The resident scored a 15 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions).
--This showed that the resident was cognitively intact.
-The resident was diagnosed with Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), and Bipolar disorder (a mood disorder that can cause intense mood swings.
Record review of the resident's Electronic Health Record (EHR), undated, showed the resident did not have a PASRR in the attached documents.
2. Record review of Resident #18's quarterly MDS, dated [DATE], showed:
-The resident was admitted to the facility on [DATE].
-The resident scored a 7 on the BIMS.
--This showed that the resident was severely cognitively impaired.
-The resident was diagnosed with Depression (a medical illness that negatively affects how a person feels, thinks and acts) and Bipolar disorder.
Record review of the resident's EHR, undated, showed the resident did not have a PASRR in the attached documents.
3. Record review of Resident #64's quarterly MDS, dated [DATE], showed:
-The resident was admitted to the facility on [DATE].
-The resident scored a 15 on the BIMS.
--This showed that the resident was cognitively intact.
-The resident was diagnosed with Anxiety disorder, Bipolar disorder and Post Traumatic Stress Disorder (PTSD -an anxiety disorder developed in reaction to physical injury or severe mental or emotional distress).
Record review of the resident' s EHR, undated, showed the resident did not have a PASRR in the attached documents.
4. During an interview on 4/2423 at 12:10 P.M. the Business Office Manager (BOM) said:
-The residents do not have a PASRR.
-The PASRR's were not received when the new company bought out the previous company.
During an interview on 4/26/23 at 3:47 P.M., the Administrator said:
-He/she was unable to find a PASRR for the residents.
-The residents were admitted from the hospital and the hospital had not sent one over.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents were offered or provided as 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 ensure the residents were offered or provided as needed showers for three sampled residents (Resident #23, #304, and #204), and to return to a resident's room to assist them after turning out the call light for one sampled resident (Resident #23), out of 21 sampled residents. The facility census was 105 residents.
Record review of the facility's policy, Shower or Tub Bath, dated February 2018 showed:
-Staff was to document the date and time the shower was performed.
-Document the name and title of the individual who performed the shower.
-Document all assessment data obtained during the shower.
-Document how the resident tolerated the shower.
-If the resident refused the shower, the reason why and the interventions taken.
-Document the signature and title of the person recording the data.
-Staff was to notify the supervisor if the resident refuses the shower.
-Staff was to notify the physician of any skin areas that may nerd to be treated.
-Report other information in accordance with facility policy and professional standards of practice.
Record review of the facility's policy, Bed Bath, dated March 2021 showed:
-Staff was to document the date and time the bed bath was performed.
-Document the name and title of the individual who performed the bed bath.
-Document all assessment data obtained during the bed bath.
-Document how the resident tolerated the bed bath.
-If the resident refused the bed bath, the reason why and the interventions taken.
-Document the signature and title of the person recording the data.
-Staff was to notify the supervisor if the resident refuses the bed bath.
-Report other information in accordance with facility policy and professional standards of practice.
Record review of the facility's policy, Answering the Call light, dated March 2021 showed:
-The purpose of this procedure was to ensure timely responses to the resident's requests and needs.
-When answering from the call light station, turn off the signal light.
-If the resident needs assistance, indicate the approximate time it would take for you to respond.
-If the resident's request requires another staff member, notify the individual.
-If the resident's request is something you can fulfill, complete the task within five minutes if possible.
-If you were uncertain as to whether or not a request could be fulfilled or if you could not fulfill the resident's request, ask the nurse supervisor for assistance.
1a. Record review of Resident #23's face sheet showed he/she was re-admitted to the facility on [DATE] with the following diagnoses:
-Diabetes ( a group of diseases that result in too much sugar in your blood).
-Paraplegia (the loss of muscle function in the lower half of your body including the legs).
Record review of the resident's Care Plan dated 12/1/22 showed:
-He/she was dependent on staff for physical needs.
-He/she was dependent on staff for bathing.
Record review of the resident's five day Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 3/28/23 showed:
-The resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 showing he/she was cognitively intact.
-He/she needed the assistance of two staff members for physical assistance for bed mobility.
-He/she had a medically complex condition.
-He/she needed the assistance of two staff members for physical assistance for bathing.
Record review of the resident's bath sheets dated March 2023 showed:
-Staff had documentation on 3/8/23 showing he/she had a shower.
-There was no documentation his/her hair was washed.
-He/she was in the hospital March 8 to March 22.
-There was no documentation of any other bath or shower had been offered.
Record review of the resident's bath sheets dated April 2023 showed:
-The resident had his/her hair washed twice.
-The record showed he/she did not receive a shower during the month.
-There was no documentation that a bath or a shower had been offered.
During an interview on 4/17/23 at 11:02 A.M. the resident said:
-He/she did not get showers.
-He/she got a bed bath but at least once a week he/she would like a shower so he/she could wash his/her hair but they don't have enough staff to do that as it takes two staff members to get him/her into the shower.
-He/she got his/her wheel chair stuck under the sink in the room trying to wash his/her hair.
-He/she may get two bed baths a week but his/her hair was washed only once a week if that.
During an interview on 4/19/23 at 11:00 A.M. the resident said:
-He/she had not had a bath in the last three weeks.
-The staff come into his/her room at 4:00 A.M. to give him/her a bath, which he/she refused.
-The shower room did not have any shampoo.
-The staff would wash his/her hair with body wash.
-He/she did not like to have his/her hair washed with body wash he/she would prefer to use shampoo and cream rinse.
Observation on 4/19/23 at 11:30 A.M. of the shower room showed:
-There was one bottle of body wash on the shelf.
-There was no shampoo or cream rinse.
During an interview on 4/21/23 Certified Nursing Assistant (CNA) D said:
-Over the weekend the facility phone was not working.
-Staff were having a hard time calling in to notify them they were not coming in to work.
-Cares were not done as they should have been, including baths.
During an interview 4/21/23 at 6:00 A.M. Licensed Practical Nurse (LPN) G said:
-There was a list of who was to have a shower on which day.
-It was at the Nurses' station and the CNA's were to check it.
-They used to have bath sheets the CNA's would fill out.
-Staff were to fill the bath sheets out each time.
-If a resident refused it should have been written on the bath sheet.
-They should have been offered a bath at a different time.
-The Nurse was to sign off on it.
-The residents should have been offered two baths/showers a week.
-The resident usually gets a bed bath not sure if he/she always gets two.
-He/she was not sure how often or how his/her hair was washed.
-Some of the staff were now documenting the showers on the computer.
-He/she has had issues with the CNA's going into resident rooms including this resident then turning off the light without assisting the resident.
During an interview on 4/24/23 at 1:00 P.M. the acting Director of Nursing (DON) said:
-He/she knew the resident had a bed bath at least weekly.
-The staff may not have charted it.
-The resident was in the hospital from [DATE] to March 22.
-The CNA or Bath Aid should have charted if the resident had a shower, bedbath or refused.
-The facility had recently changed from a paper system to a computer system.
-The resident should have had a shower if he/she wanted one.
-Residents should have been offered a bath or shower twice a week.
-There should have been shampoo in the supply room.
1b. During an interview on 4/17/23 at 11:02 A.M. the resident said:
-He/she would put on the call light.
-He/she would at times need help getting something from his/her closet.
-He/she was not able to reach anything in his/her closet as he/she could not walk.
-Staff would come into the room and shut off the light telling him/her they would return after they finished with another resident.
-Staff would leave the room without getting him/her what he/she needed and would not return later.
During an interview on 4/19/23 at 9:30 A.M. LPN A said:
-He/she had issues with the CNA's going into resident rooms including Resident #23 and turning off the call light without assisting the resident.
-He/she had told the former Director of Nursing (DON).
-There was no change.
-This happened weekly.
During an interview 4/21/23 at 6:00 A.M. LPN G said:
-He/she had issues with the CNA's going into resident rooms including Resident #23 and turning off the call light without assisting the resident.
-He/she had talked to the CNA's about this issue and it still happened.
2. Record review of Resident #304's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Epilepsy - a disorder in which nerve cell activity in the brain is disturbed, causing seizures( abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness).
-Head injury.
-Difficulty in walking.
-History of falling.
Record review of the resident's care plan showed:
-There was no care plan.
-NOTE: The surveyors were informed that a previous employee had deleted most of the resident's care plans when their employment was terminated.
Record review of the Entry tracking record dated 4/5/23 showed:
-It was blank.
-There was no MDS done as of 5/1/23.
Observation on 4/17/23 at 9:00 A.M. showed the resident had greasy dirty hair which had not been combed.
During an interview on 4/17/23 at 9:15 A.M. the resident declined to be interviewed.
Observation on 4/20/23 at 10:00 A.M. showed the resident had greasy uncombed hair.
Record review of the bath sheets dated April 2023 showed:
-There was no documentation that showed if the resident had a shower/bath, or refused his/her shower/bath.
3. Record review of Resident #204's admission record showed he/she admitted on [DATE] and discharged to the hospital on 4/4/23 with the following diagnoses:
-Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing).
-Hypertension (HTN-abnormally high blood pressure that's not the result of a medical
condition).
-Adult failure to thrive (is a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity).
Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
-Benign Prostatic Hyperplasia [BPH-enlargement of the prostate gland blocks the urethra (the tube that carries urine from the bladder out of the body) causing problems with urinating).
-Encounter for palliative care (comfort care prevents or treats symptoms and side effects of diseases and also treats emotional, social, practical, and spiritual problems that illness can bring up).
Record review of the resident's Care Plan dated 1/25/22 and updated 3/28/23 showed:
-He/She had Emphysema (the air sacs of the lungs are damaged and enlarged, causing breathlessness)/COPD.
-He/she was admitted to Hospice.
-ADL self-care performance deficit for bathing/showering.
--Intervention for bathing/showering:
---Staff will assist resident with bath/shower twice weekly and PRN (as needed) through next review.
---Resident required staff assistance for dressing, oral care, toileting, and with transfers.
Record review of the resident's Annual MDS dated [DATE] showed:
-admitted on [DATE].
-Required limited assistance of one person for dressing.
-Required limited assistance of one person for toileting.
-Required limited assistance of one person for personal hygiene.
-Required physical help in part of bathing with limited assistance of one person.
-Was steady at all times for moving from seated to standing position and ambulating.
-Resident used a walker.
-Had following diagnoses;
--Debility.
--Cardiorespiratory (the ability of the heart lungs to deliver oxygen to working muscles).
--Malnutrition or at risk for malnutrition.
--Pulmonary concerns: Asthma, COPD, or chronic lung disease.
Record review of the resident's shower/bathing sheet dated March 2023 showed:
-His/Her bath days were Tuesday, Friday, and Sunday.
-He/she received one shower on Wednesday 3/8/23 at 5:26 A.M.
-There was no documentation showing he/she had received any other baths/showers in March 2023.
Record review of the resident's shower/bathing sheet dated April 2023 showed:
-His/Her bath days were Tuesday, Friday, and Sunday.
-There was no documentation that showed he/she received any baths/showers in April.
During an interview on 4/26/23 at 2:11 P.M., CNA D said:
-Residents got showers at least weekly.
-Some residents took their own showers.
-Shower Aides do the showers.
During an interview on 4/26/23 at 2:13 P.M., CNA E/shower aide said:
-Residents got showers twice a week.
-He/she worked Monday through Friday 9:00 A.M. to 9:00 P.M.
-Worked all of the facility with another shower aide who was off today.
-There was a shower book at each Nurses Station.
-The room number of the resident determined what two days a resident got their shower.
-Depending on the room number the shower days were Monday/Thursday; Tuesday/Friday; Wednesday/Saturday.
-The CNA's working Saturday gave the resident those showers.
-Some residents do their own showers and he/she would just set-up towels, put towel on floor to prevent falls, turn on the water to be sure the temperature was not too hot or cold.
-He/she also did a skin check and would let the nurse know if the resident had any issues.
-He/she charted the shower in the electronic charting and on the paper shower sheet in the shower book.
During an interview on 4/26/23 at 2:19 P.M., LPN F said:
-The shower aides would let the nurse know if a resident refused a shower.
-The nurse would then try to talk to the resident to see why they didn't want to take the shower.
-If the resident still refused, staff would try at a different time.
-The shower aide offered a bed bath to the residents who refused a shower, a lot of residents liked bed baths.
-If the resident still refused, the shower aide would chart it in the electronic charting and on the paper shower book.
-Some residents only liked a certain staff member to assist with a shower.
-If that staff member was available he/she would give the resident the shower.
-When the aide gave the resident a shower he/she would let the Nurse know if there were any skin issues.
-He/She goes in when the resident was going into the shower to do a skin assessment and if the aide found anything during the shower he/she would let him/her know.
-All showers were charted in the electronic charting and in the paper book.
-If it wasn't charted it didn't get done.
4. During an interview on 4/26/23 at 3:45 P.M. the acting DON said:
-If a shower or bath was not documented it was not done.
-It should have been documented on the computer.
-If the resident took his/her own shower the shower aide or CNA should still chart that the resident took a shower and mark it as independent.
-If a resident took a shower on a different day than their scheduled shower day it could be charted as PRN.
-Until recently the facility had been using paper shower sheets to document showers/baths.
-There was a shower schedule at each nurses' station showing which resident was scheduled each day.
-Residents should have been offered a shower or bath twice a week.
-Residents could have had a shower or bath more often if they chose to.
-The nurse should try and find out why the resident was refusing to take a shower.
-The resident should be offered a bed bath if refusing to take a shower.
-Staff should document if a resident refused a bath or shower on the computer.
-The Nurse would sign off on bathing and they were responsible to ensure baths were done.
-The nurse needed to find out why the resident was not wanting to shower and find ways that would encourage him/her to take the shower like at a different time or day.
-If a shower was missed it would pop up on the computer program.
-They have not been short staffed, residents should have had a shower if they wanted one.
-Staff should answer call lights within 15 minutes.
-He/she heard about staff going into a resident's room and shutting off the call light without taking care of the resident's needs.
-He/she has done 1 to 1 education with certain staff about shutting off the call light telling the resident they would come back to help them then they don't go back to assist the resident with their needs.
MO00216707
MO00216871
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The facility maintained a census of greater than 60 ...
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Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The facility maintained a census of greater than 60 residents and this deficiency had the potential to affect all residents. The facility census was 105 residents.
The facility policy for staffing of RN coverage for eight consecutive hours per days was requested and was not received by the end of the survey.
1. Record review of the worked staffing sheets on 4/24/23 at 11:31 A.M., showed there was no RN scheduled for eight consecutive hours for the weekend of Friday 4/14/23; Saturday 4/15/23; or Sunday 4/16/23.
During an interview on 4/21/23 at 6:04 A.M., Licensed Practical Nurse (LPN) E said:
-He/she worked the night shift 6:00 P.M., to 6:00 A.M.
-Sometimes there was an RN working the night shift.
-There should be an RN working on the day shift.
-The Director of Nursing (DON) was an RN and he/she worked day shift.
During an interview on 4/21/23 at 6:46 A.M., LPN D said:
-The DON was an RN and was in the facility during the weekdays.
-The DON comes in when needed over the weekends.
During an interview on 4/24/23 11:31 A.M., Acting DON who was an RN said:
-The previous DON quit the week before.
-He/she has been the DON for almost two weeks.
-Was not aware that there was no RN working the weekend of Friday 4/14/23; Saturday 4/15/23; or Sunday 4/16/23 shifts.
-He/she had come in during that weekend several times just in a managerial capacity for different situations that had occurred but was not there for eight hours at a time.
-Had an RN weekend supervisor who covered weekends and he/she quit.
-Now there was one weekend of the month with no RN coverage.
-The facility had tried to get RN's to switch weekends and no one would.
During an interview on 4/26/23 at 2:13 P.M., Certified Nurses Aide (CNA) E said:
-There was usually an RN working the day shifts.
-The DON was here most weekdays.
During an interview on 4/26/23 at 2:19 P.M., LPN F said he/she thought there was always an RN working one of the shifts each day.
During an interview on 4/26/23 at 3:46 with the DON, the Administrator, and the Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator said:
-There should be an RN on for at least 8 consecutive hours in a 24 hour time frame.
-They are trying to have one RN for every 12 hours.
-The staffing person was off on leave and would be back on May 15, 2023.
-The DON would be responsible to come in to do any RN duties if no RN on duty.
-Working on an on-call schedule where an RN would come in and work an 8 hour shift if there was no RN.
-Administration was not aware of this last weekend with no RN coverage due to a call off.
-The facility had offered bonuses to RN's to come in extra to cover a shift.
-The facility had an agency they could use if know in advance that they need a RN.
-If an RN called off at last minute it was harder to find an agency RN to come in.
-The facility now has a sister facility that they could start to call on.
-The facility has jobs openings posted on different sites for RN positions and have contacted previous candidates to see if they were still available to be hired.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
4. Record review of the Narcotic Count Sheet for the 100 hallway Nurses' Medication cart dated February 2023 showed:
-Only February 22 through February 28 was received.
-On 2/22/23 there were three m...
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4. Record review of the Narcotic Count Sheet for the 100 hallway Nurses' Medication cart dated February 2023 showed:
-Only February 22 through February 28 was received.
-On 2/22/23 there were three missing signatures.
-On 2/26/23 there was one missing signature.
-On 2/27/23 there were two missing signatures.
Record review of the Narcotic Count Sheet for the 100 hallway Nurses' Medication cart dated March 2023 showed:
-On 3/7/23 there were two missing signatures.
-On 3/8/23 there were two missing signatures.
-On 3/10/23 there was one missing signature.
-On 3/11/23 there were two missing signatures.
-On 3/12/23 there were three missing signatures.
-On 3/13/23 there was one missing signature.
-On 3/15/23 there were two missing signatures.
-On 3/17/23 there were two missing signatures.
-On 3/21/23 there were two missing signatures.
-On 3/22/23 there were two missing signatures.
-On 3/23/23 there was one missing signature.
-On 3/24/23 there was one missing signature.
-On 3/25/23 there were two missing signatures.
-On 3/27/23 there were two missing signatures.
-On 3/28/23 there were two missing signatures.
-On 3/29/23 there were two missing signatures.
-On 3/30/23 there were three missing signatures.
-On 3/31/23 there was one missing signature.
Record review of the Narcotic Count Sheet for the 100 hallway Nurses' Medication cart dated April 2023 showed:
-On 4/4/23 there were two missing signatures.
-On 4/8/23 there were two missing signatures.
-On 4/9/23 there were two missing signatures.
-On 4/12/23 there were two missing signatures.
-On 4/13/23 there were three missing signatures.
-On 4/14/23 there was one missing signature.
-On 4/20/23 there were two missing signatures.
Observation on 4/21/23 at 5:59 A.M. of the Narcotic count sheet on the 100 hallway Nurses' Medication cart with LPN G showed LPN G, the night shift charge nurse, had pre-signed the Narcotic count sheet before the day nurse came on duty.
5. During an interview on 4/21/23 at 6:00 A.M. LPN G said:
-He/she should not have signed the narcotic sheet before the day nurse arrived and counted the narcotics with him/her.
-There should always be two nurses who count the narcotics and they should both sign at that time.
-Many areas on the narcotic sheet do not have signatures.
-The count had always been correct.
-The DON was responsible to ensure the count was correct and the documentation was correct.
-There was an acting DON currently as the previous DON left a couple weeks ago.
During an interview on 4/26/23 at 2:02 P.M. LPN B said:
-Staff should not sign the narcotic sheet before the other shift arrived.
-Two nurses were supposed to count the narcotics together at the beginning of the shift and at the end of the shift.
-The DON was responsible to ensure the staff was counting the narcotics at the beginning and at the end of their shift.
During an interview on 4/26/23 at 3:45 P.M. the acting DON said:
-Nursing staff should not pre sign the narcotic count sheet before the next shift arrived.
-There should have been two nurses count the narcotics together and then sign the sheet for each shift.
-There should have been the off-going nurse and the on-coming nurse count and sign for the narcotics.
-The DON was responsible for ensuring the narcotic count was done appropriately.
Based on observation, interview and record review, the facility failed to ensure the narcotic count sheet was signed by both the on-coming and the off-going nurses to verify the correct count of narcotics. The facility census was 105 residents.
Record review of the facility's Controlled Substance policy dated April 2019 showed:
-The facility complies with all laws, regulations and other requirements related to the handling, storage, disposal, and documentation of controlled medications.
-Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.
-Controlled medications are counted at the end of each shift.
-The nurse coming on duty and the nurse going off duty determine the count together.
-Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing (DON) services immediately.
1. Record review on 4/21/23 at 6:47 A.M., of the facility's [NAME] Nurses Station Narcotic and Hypnotic Inventory Sheet in the green narcotic book for the time period of 4/9/23 through 4/21/23 showed the following number of missing signatures out of the required four signatures a day showed:
-On 4/11/23 there was one missing signature.
-On 4/12/23 there was one missing signature.
-On 4/14/23 there were two missing signatures.
-On 4/15/23 there were two missing signatures.
-On 4/16/23 there were two missing signatures.
-On 4/20/23 there was one missing signature.
2. Record review on 4/21/23 at 6:50 A.M., of the facility's [NAME] Nurses Station Narcotic and Hypnotic Inventory Sheet in the black narcotic book for the time period of 4/9/23 through 4/21/23 showed the following number of missing signatures out of the required four signatures a day showed:
-On 4/11/23 there were two missing signatures.
-On 4/12/23 there was one missing signature.
-On 4/14/23 there were two missing signatures.
-On 4/15/23 there were four missing signatures.
-On 4/16/23 there was one missing signature.
-On 4/18/23 there were two missing signatures.
-On 4/19/23 there was one missing signature.
-On 4/20/23 there was one missing signature.
3. During an interview on 4/21/23 at 6:52 A.M., Licensed Practical Nurse (LPN) E said:
-The on-coming and the off going nurses count the narcotic mediations each shift.
-Both nurses sign the narcotic count sheet that the count was correct.
-The narcotic count sheet should have a signature for the on-coming and off going nurse for each shift.
During an interview on 4/21/23 at 7:00 A.M., the Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator said:
-The nurses do 12 hour shifts, 6:00 A.M., to 6:00 P.M., and 6:00 P.M., to 6:00 A.M.
-Both the on-coming and the off-going nurses count the narcotic medications at the beginning and end of their shift.
-Both the on-coming and the off-going nurses for each shift sign the narcotic count sheet indicating the count was correct for that shift.
During an interview on 4/26/23 at 3:46 P.M., the DON, Administrator and the MDS Coordinator said:
-The narcotic count sheet should be signed by the two nurses who counted the narcotic medications indicating the count was correct.
-The narcotic count sheet is signed at each shift change.
-The on-coming nurse should not sign in the off going spot ahead of time.
-The DON was responsible for auditing the narcotic count sheets for the correct medication count and that it was signed each shift.
-The DON had been at the facility for two weeks and had not audited the narcotic count sheets.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain Drug Regimen Review (DRR) reports and failed to ensure the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain Drug Regimen Review (DRR) reports and failed to ensure the reports were acted upon for three sampled residents (Residents #12, #24 and #35) out of five residents sampled for medication review. The facility census was 105 residents.
Record review of the facility's Medication and Prescribing - Clinical Protocol policy dated as revised April 2018 showed:
-The staff and physician would periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications.
-There were no instructions regarding the completion of the DRR reports and acting upon them.
1. Record review of Resident #12's care plan dated as admission date 2/7/22 showed the resident:
-Was at risk for abnormal bleeding due to taking blood thinning medication.
-Had a diagnosis of diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Used antidepressant (medication used to treat clinical depression-a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life) medication.
-Had chronic pain.
-Was on hospice (end of life care).
Record review of the resident's pharmacy notes showed:
-A DRR was completed and referred to the pharmacy report for the recommendations on 4/20/22, 5/25/22, 7/25/22, 8/24/22, 10/26/22, 11/22/22, 12/26/22, 1/24/23, 2/22/23, 3/24/23 and 4/19/23.
-No pharmacy note for September 2022.
Record review of the resident's medical records showed none of the recommendations or the responses to the above DRRs.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 2/25/23 showed the resident received insulin (lowers the level of glucose (a type of sugar) in the blood), antidepressant, anticoagulant (medication used to slow down the blood clotting process) and diuretic (elevates the rate of urination) medications seven out the past seven days.
Record review of the resident's April 2023 Physician's Order Sheet (POS) showed some of the resident's physician's orders included insulin, anticoagulant, opioid (pain medications used to treat severe pain) pain medication, diuretic and anticonvulsant (prevents or reduces seizures) medications.
2. Record review of Resident #24's care plan as admission date 3/9/21 showed the resident received opioids, anticoagulant, antidepressant, antipsychotic (class of medicines used to treat psychosis and other mental and emotional conditions), diuretics, insulin, sedatives (calming and/or sleep-inducing) and antibiotic (used to treat infections) medications.
Record review of the resident's pharmacy notes showed:
-A pharmacy recommendation on 1/30/22 to add 30 minutes before meal to Pantoprazole (used to treat acid reflux) order to increase effectiveness.
-A pharmacy recommendation on 3/16/22:
--Resident is taking the following psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications: Alprazolam (antianxiety) 0.5 milligrams (mg), Citalopram (antidepressant) 10 mg, and Quetiapine (antipsychotic) 300 mg.
--It is recommended to attempt a gradual dose reduction (GDR) in psychiatric medication annually to ensure residents are on the lowest effective dose.
--If clinically relevant, please consider reducing one or more of the preceding medications.
-A DRR was completed and referred to the pharmacy report for the recommendations on 4/21/22, 5/26/22, 6/30/22, 7/25/22, 8/26/22, 9/21/22, 10/28/22, 11/23/22, 1/23/23, 2/23/23, and 4/20/23.
-No pharmacy note for September 2022.
Record review of the resident's medical records showed none of the recommendations or the responses to the above DRRs.
Record review of the resident's annual MDS dated [DATE] showed:
-The resident received antipsychotic, antianxiety, antidepressant and opioid medications seven out of the past seven days.
-The physician documented on 3/15/23 that a GDR of the resident's antipsychotic medication was clinically contraindicated.
Record review of the resident's April 2023 POS showed:
-Some of the resident's physician's orders included anti-anxiety, opioid, sedative-hypnotic, antipsychotic, antidepressant and anticonvulsant medications.
-A physician's order dated 3/9/21 for Pantoprazole Sodium Tablet Delayed Release 40 mg, give one tablet by mouth one time a day and it did not include 30 minutes before meal in the order to increase effectiveness as recommended on 1/30/22.
-A physician's order dated 3/9/21 for Citalopram Hydrobromide Tablet 10 mg, give one tablet by mouth one time a day.
-A physician's order dated 3/9/21 for Quetiapine Fumarate Tablet 300 mg, give one tablet by mouth one time a day.
3. Record review of Resident #35's care plan as admission date 4/3/22 showed the resident received antipsychotic and anticoagulant medications.
Record review of the resident's pharmacy notes showed a DRR was completed and referred to the pharmacy report for the recommendations on 4/20/22, 5/25/22, 6/30/22, 7/25/22, 8/24/22, 9/21/22, 10/26/22, 11/22/22, 12/26/22, 1/24/23, 3/24/23, and 4/19/23.
Record review of the resident's medical records showed none of the recommendations or the responses to the above DRRs.
Record review of the resident's quarterly MDS dated [DATE] showed:
-The resident received antipsychotic, antidepressant and anticoagulant medications.
-A GDR of the resident's antipsychotic medication had not been attempted and the physician did not document that a GDR was clinically contraindicated.
Record review of the resident's April 2023 POS showed some of the resident's physician's orders included anticoagulant, antipsychotic and opioid medications.
4. During an interview on 4/26/23 at 10:24 A.M., Registered Nurse (RN) A said:
-The charge nurses don't have anything to do with the DRRs.
-The DRRs go to the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) and they handle them.
During an interview on 4/26/23 at 3:44 P.M. with the Administrator, acting DON and the MDS Coordinator:
-The acting DON said:
--The pharmacist did the DRRs and sent them to the DON via email.
--If an order needed a minor thing like a time change, the DON would address it.
--For more significant recommendations, the DON sent the DRR to the physician.
-The MDS Coordinator said:
--The physician responded on the DRR papers and then gave them to the DON.
--The DON and ADON were responsible for entering any order changes that resulted from a DRR.
--The DON and ADON who were responsible for the DRRs had not been employed at the facility for the past couple of weeks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the medication carts were locked when the nursing staff was not within sight of the cart; to ensure there were not loo...
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Based on observation, interview, and record review, the facility failed to ensure the medication carts were locked when the nursing staff was not within sight of the cart; to ensure there were not loose pills in the medication cart drawers; and to ensure cleaning products were not in the same drawer as the residents' medications. The facility census was 105 residents.
Record review of the facility's policy, Storage of Medications, dated November 2020 showed:
-The facility stores all drugs and biologicals in a safe, secure, and orderly manner.
-Drugs and biologicals used in the facility were stored in locked compartments.
-Only persons authorized to prepare and administer medications were to have access to locked medications.
-The nursing staff was responsible for maintaining medication storage in a clean, safe and sanitary manner.
-Compartments (including but not limited to drawers, cabinets, rooms, refrigerator, carts, and boxes) containing drugs and biologicals were locked when not in use.
-Unlocked medication carts were not left unattended.
1. Continuous observation on 4/17/23 from 12:16 P.M. to 12:36 P.M. showed:
-The Nurses' cart on 100 hallway was unlocked with two residents sitting within an arms length of the unlock cart.
-Licensed Practical Nurse (LPN) F was off the unit for 20 minutes.
2. Observation on 4/21/23 at 6:50 A.M. of the Certified Medication Technician (CMT) medication cart with CMT B showed:
-There were 20 loose pills in the medication cart.
-There were 10 white round pills.
-There were three yellow oblong gel pills.
-There were two round blue pills.
-There were five round yellow pills.
-There were bleach wipes in the same compartment with the resident's medications.
During an interview on 4/21/23 at 7:00 A.M. CMT B said:
-The medication carts were to be cleaned every Sunday by the CMT.
-There should not have been any loose pills in the medication cart.
-There should not have been bleach wipes with the resident's medications.
-The medication cart should never be left unlocked when unattended.
3. Observation on 4/21/23 at 7:20 A.M. during medication pass with Licensed Practical Nurse (LPN) C showed:
-The nurses' medication cart was unlocked for 5 minutes while he/she went into a room to perform an accu check (blood sugar test) and administer insulin to a resident.
-A resident walked by the unlocked cart within one foot of the cart.
During an interview on 4/21/23 at 7:30 A.M. LPN C said:
-He/she should have locked the medication cart when he/she went into the resident's room.
-The medication cart should be locked unless you are in front of it.
-The medication carts should be cleaned frequently by who ever uses it.
-There should not have been bleach wipes in the same drawer as the residents' medications.
-There should not have been any loose pills in the bottom of the drawers.
During an interview on 4/26/23 at 2:02 P.M. LPN B said:
-Whoever uses the medication carts should be responsible for cleaning them at the end of the shift.
-There should not have been any loose pills in the bottom of the drawers in the medication cart.
-You should never leave the medication cart unlocked if not in front of it.
-There should not have been bleach wipes in the drawer with the medications.
During an interview on 4/26/23 at 3:45 P.M. the acting Director of Nursing (DON) said:
-There should not have been any loose pills in the medication cart.
-The medication cart should have been cleaned and checked by the CMT or Nurse who had been using it at the end of their shift.
-During orientation the staff was educated on how the medication cart should have been set up and maintained.
-Bleach wipes should not have been in the drawers with the medications.
-He/she expected the medication cart to be locked if the staff was not in front of it.
-The Pharmacist also was to look at the medication carts on a monthly basis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of resident #79's admission MDS dated [DATE], showed:
-The resident was admitted to the facility on [DATE].
-Th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of resident #79's admission MDS dated [DATE], showed:
-The resident was admitted to the facility on [DATE].
-The resident scored a 15 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.
--This showed that the resident was cognitively intact.
-The resident was diagnosed with Chronic Obstructive Pulmonary Disease (COPD- a progressive lung disease that makes it hard to breathe), high blood pressure, anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), and heart failure (inability for heart to pump enough blood).
Record review of the residents Immunization Report, undated, showed the resident had no immunizations noted.
5. During an interview on 4/26/23 at 10:24 A.M., Registered Nurse (RN) A said:
-The flu and pneumonia vaccines were offered during flu season.
-The office staff had the resident or their responsible sign the permission form for the vaccines and the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) administered the vaccines.
During an interview on 4/26/23 at 3:44 P.M. with the Administrator, the Acting DON and the MDS Coordinator, the MDS Coordinator said:
-The facility should offer the flu vaccine during flu season and pneumonia vaccine to all residents.
-The admitting nurse was responsible for offering vaccines to new residents upon admission.
-Immunizations should be documented on the immunization tab.
3. Record review of Resident# 88's quarterly MDS dated [DATE] showed the following assessment of the resident:
-He/she was admitted to the facility on [DATE].
-He/she was at least [AGE] years old.
-He/she was moderately cognitively impaired.
-He/she did not receive the flu vaccine in the facility in this year's flu season.
-He/she was in the facility during the flu season.
-He/she did not have a medial contraindication to the flu vaccine.
-There was no shortage of the flu vaccine.
-He/she was offered the pneumonia vaccine and declined it.
Record review of the resident's current vaccine tab showed:
-The resident did receive the flu vaccine on 10/21/22.
-There was no documentation when or if the resident had ever had the pneumonia vaccine.
2. Record review of Resident #58's Annual MDS dated [DATE] showed:
-He/she was admitted to the facility on [DATE].
-He/she was discharged from facility on 3/22/22
-He/she was readmitted to the facility on [DATE]
-He/she was at least [AGE] years old.
-He/she was cognitively intact.
-He/she did not receive the flu vaccine in the facility in this year's flu season.
-He/she was not in the facility during the flu season.
-The flu vaccine was not offered and declined.
-No medical contraindication to the flu vaccine was noted.
-There was no shortage of the flu vaccine.
-The resident's pneumonia vaccine status was not up to date due to medical contraindication.
-NOTE: He/she was in the facility during flu season and should have been offered the flu vaccine.
Record review of the Resident's current electronic Immunization tab showed no information for the flu or pneumonia vaccine for the resident.
Based on interview and record review, the facility failed to ensure two sampled residents (Resident #35 and #58,) out of five residents sampled for vaccination review were offered the influenza (flu) vaccine and three sampled residents (Resident #35 #58, and #88) were offered a pneumococcal (pneumonia) vaccine. The facility census was 105 residents.
Record review of the facility's flu vaccine policy dated March 2022 showed:
-All residents who had no medical contraindications to the vaccine would be offered the flu vaccine annually.
-The facility would provide pertinent information about the significant risks and benefits of vaccines to residents.
-Between October 1st and March 31st each year, the flu vaccine would be offered to residents unless the vaccine was medically contraindicated or the resident was already immunized.
-Any refusal of a vaccine by a resident would be charted in their medical record.
Record review of the facility's pneumonia vaccine policy dated March 2022 showed:
-Prior to or upon admission, residents were to be assessed for eligibility to receive the pneumonia vaccine, and when indicated, were offered the vaccine within 30 days of admission.
-The facility would provide pertinent information about the significant risks and benefits of vaccines to residents.
-Pneumonia vaccines were given to residents unless medically contraindicated, already given or refused.
-For each resident who received the vaccine, the date of the vaccine should be documented in the resident's medical record.
1. Record review of Resident #35's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/12/23 showed the following assessment of the resident:
-Was admitted to the facility on [DATE].
-The resident was at least [AGE] years old.
-Was cognitively intact.
-Did not receive the flu vaccine in the facility in this year's flu season.
-Was in the facility during the flu season.
-Did not receive the flu vaccine out of the facility.
-The flu vaccine was not offered and declined.
-The resident had no medical contraindication to the flu vaccine.
-There was no shortage of the flu vaccine.
-The resident's pneumonia vaccine status was not up to date and no information was included regarding why it was not up to date.
Record review of the resident's current vaccine tab showed:
-The resident received the flu vaccine 10/29/21.
-There was no documentation regarding the pneumonia vaccine.
Record review of the resident's historical immunization report printed on 4/24/23 showed the resident received a flu vaccine and a pneumonia vaccine but the dates were not included.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide 12 hours of training/in-services to include behavior & dementia training, abuse prevention, resident rights, care of the cognitivel...
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Based on interview and record review, the facility failed to provide 12 hours of training/in-services to include behavior & dementia training, abuse prevention, resident rights, care of the cognitively impaired resident, and training areas of weakness as determined in the Nurse aides' performance reviews for five out of five Certified Nursing Assistants (CNA). This had the potential to affect all residents. The facility census was 105 residents.
The facility policy for staffing in-services and training was requested and was not received by the end of the survey.
1. Record review of the inservice/trainings dated April 2022 to April 2023 that were provided showed:
-Abuse Policy presented by the Regional Social Services (RSS) dated 2/14/23 to all department heads, then the department heads in-serviced their department staff.
-Handwashing on 4/20/23 did not show who presented the in-service. It showed as qualifications a Registered Nurse (RN).
-Infection Control covering Carbapenem-Resistant Acinetobacter Baumannii (CRAB- bacteria found in environment, especially in soil and water can cause infections of the blood, urinary tract, lungs, wounds). Presented by the Director of Nursing (DON).
-No other in-services were given.
-NOTE: The last 12 months of staff in-services and the 12 months of CNA training was requested and the above were the only trainings received.
During an interview on 4/26/23 at 2:00 P.M., CNA C said:
-He/she had trainings in the past but did not remember how long ago.
-The new administration had started in-services for the last two months.
-Just had an in-service on handwashing and on infection control CRAB.
During an interview on 4/26/23 at 2:11 P.M., CNA D said:
-He/she had only been at this facility for a couple of weeks.
-Had a lot of education on taking care of the residents during orientation.
-Just had an in-service on handwashing.
During an interview on 4/26/23 at 2:13 P.M., CNA E said:
-He/she had trainings in the past on behaviors and how to deal with residents.
-The new administration had started doing monthly in-services.
-Heard there was an in-service on handwashing but he/she did not attend.
During an interview on 4/26/23 at 2:20 P.M., CNA F said:
-He/she had trainings in the past on behaviors and what to do if residents were acting out.
-The new administration had started doing monthly in-services.
-There was an in-service on handwashing he/she did not attend.
During an interview on 4/26/23 at 2:30 P.M., CNA G said:
-He/she had trainings in the past but did not remember how long ago.
-Administration had started doing monthly in-services.
-He/she might of been off for the Handwashing in-service.
During an interview on 4/26/23 at 3:46 P.M., the DON, Administrator and the Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator said:
-CNA's should have 12 hours a year in-services/training covering areas such as: resident behaviors, resident rights, abuse and neglect.
-The DON was responsible to see that in-services were scheduled and done.
-Was unable to find in-services/training records for the staff from the previous Administration.
-This administration had not done any behavioral in-services in the last two months.
-There should be in-services to address the needs of the residents.
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 keep the kitchen walk-in refrigerator floor clean; to maintain sanitary utensils and food preparation equipment; to keep tras...
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Based on observation, interview, and record review, the facility failed to keep the kitchen walk-in refrigerator floor clean; to maintain sanitary utensils and food preparation equipment; to keep trash dumpster's closed; to change the deep fryer oil in a timely manner; failed to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; failed to separate damaged foodstuff; to store food within acceptable temperature parameters; and to ensure the proper refrigeration of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 105 residents with a licensed capacity for 120 residents at the time of the survey.
1. Record review of an open dietary binder on the table outside the Dietary Manager office, showed Service Line Checklist forms for 4/10/23 through 4/15/23 with recorded food temperatures for only 7 out of a possible 18 meals, and no completed forms for either the previous day (4/16/23) or current day (4/17/23).
Observations during the initial kitchen inspection on 4/17/23 between 9:16 A.M. and 9:47 A.M. showed the following:
-The kitchen ice machine had dirt on the lid's underside center hinge and white streaks on the outer edge above the lid and the inner right side of the lid frame.
-An approximately (appx.) 22 inch (in.) diameter (dia.) fan on a roller cart next to the ice machine and an identical fan on the floor by the food preparation table with a food processor on it were both on and blowing air through their front guards that were covered with excess lint.
-The microwave had splatters on the inside, an appx. 1 in. dia. glob of food residue on the glass turntable, and an unopened strawberry jam packet underneath the glass.
-The manual can opener had a build-up of black residue on the blade.
-The green, red, and brown cutting boards were excessively scored to the point of plastic flaking off.
-On the can dispenser rack a large 7 pound (lb.) can of butterscotch pudding had a dent towards the bottom on one side.
-A plastic drawer of scoops had a multitude of crumbs in the bottom.
-A white spatula on the utensil rack over the double sink was heavily chipped on the blade and handle.
-The convection oven had food residue, streaks, spills, and crumbs in the bottom.
-The sugar and flour bins both had their scoop sitting inside.
-An opened 4 lb. can of peanut butter in the dry storage room had its lid partially open.
-There was a plastic container lid, paper, a butter pod, and numerous new potatoes on the floor underneath the racks in the walk-in refrigerator.
-Another walk-in felt warm inside with 8 cartons of 40/4.23 ounce (oz.) apple juice boxes, 3 cartons of 24/10 oz. grape juice bottles, and 4 boxes of 4 oz. apple juice cups stored inside, a thermometer that was topped out at 80 degrees Fahrenheit (F), and the gasket at the hinged side was dislodged.
-Outside the kitchen's back door a middle dumpster's west lid was flipped back open with cardboard boxes piled above the dumpster edge and the east dumpster's east lid was completely off and lying in the gravel appx. 20 feet away.
Observations during the facility Life Safety Code (LSC) outer perimeter inspection with the Director of Maintenance Director (DOM) on 4/17/23 between 1:31 P.M. and 1:57 P.M. showed the following in the southwest back lot:
-The middle dumpster's west lid was flipped back open with cardboard boxes piled above the dumpster edge.
-The east dumpster's east lid was completely off and lying in the gravel appx. 20 feet away.
Observations during the follow-up kitchen inspection on 4/18/23 between 8:58 A.M. and 9:17 A.M. showed the following:
-The oil in the deep fryer was so dark the bottom basket resting bars could not be seen.
-In the dry storage room on the top shelf of the southeast shelf unit was an opened 1 gallon (gal.) jug of soy sauce appx. 4/5 full with a back label that read Refrigerate After Opening for Quality.
-The warm walk-in with the multitude of small cartons, cups, and bottles of various juices inside still had a thermometer topped out at 80 degrees F, instead of being within the 50 - 70 degree F industry standard.
During an interview on 10/12/22 09:17 A.M. the District Dietary Manager said the warmer walk-in was now just used for dry storage.
During an interview on 4/20/23 at 10:36 A.M. the Dietary Manager said the following:
-All foodstuffs should be stored at the correct temperature.
-The dietary aides were responsible for cleaning all kitchen floors after each shift.
-The west walk-in has been used for additional dry storage for over a year.
-Damaged foodstuffs should be sent back to the vendor for credit.
-Food preparation areas and items should be kept free from dirt and lint.
-Food preparation items and utensils should be cleaned daily.
-Utensil storage drawers should be cleaned weekly.
-Food temperatures should be taken and recorded at every meal to ensure they are fully cooked and served hot enough.
-They change the deep fryer oil every week on Mondays.
-Dietary, housekeeping, and nursing all use the dumpster's out back.
Observations in the southwest back lot on 4/21/23 at 11:11 A.M. showed both of the middle dumpster's lids were flipped back open and the east dumpster's east lid was completely off and lying in the gravel appx. 20 feet away.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed:
-Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
-Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of resident #79's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of resident #79's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/20/23, showed:
-The resident was admitted to the facility on [DATE].
-The resident scored a 15 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.
--This showed that the resident was cognitively intact.
-The resident was diagnosed with Chronic Obstructive Pulmonary Disease (COPD- a progressive lung disease that makes it hard to breathe), high blood pressure, anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), and heart failure (inability for heart to pump enough blood).
Record review of the residents Immunization Report, undated, showed:
-The resident received the first step TB Mantoux PPD on 3/10/2023.
-Results showed a negative reading of 0 mm with no date showing when the test was read.
-There was no notation the resident received the second step.
7. Record review of Resident # 88's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).
-Acute pain.
Record review of the resident's Quarterly MDS dated [DATE] showed his/her BIMS score was 12 out of 15 moderately cognitively impaired.
Record review of the facility's Immunization Report, date range 4/1/22 to 4/30/23 showed:
-Step one of the TB test was given on 6/25/23.
-The result was negative.
-There was no documentation of what date the TB test was read.
-There was no documentation that the second TB test was administered.
8. During an interview on 4/26/23 at 10:24 A.M., Registered Nurse (RN) A said the charge nurse was responsible for doing the TSTs.
During an interview on 4/26/23 at 3:44 P.M. with the Acting DON (DON), the Administrator and the Minimum Data Set Coordinator showed:
-The MDS Coordinator said:
--A two-step TST was required for residents upon admission.
--The second TSTs was supposed to be administered 14 days apart from the first.
--The resident TSTs should be documented on the immunization tab and include when it was given, when it was read and the results.
--The admitting nurse was responsible for administering the first TST.
-The Acting DON said:
--The reading of the first TST and doing the second-step TST automatically populated on the TAR for the residents.
--They were supposed to do annual TB screenings for residents.
9. Record review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Pressure ulcer Stage IV (a deep wound reaching the muscles, legiments, and bone)(unspecified site).
-Paraplegia (loss of muscle function in the lower half of the body including the legs).
Record review of the resident's MDS five day look back dated 3/28/23 showed:
-He/she had a BIMS score of 15 out of 15 showing he/she was cognitively intact.
-He/she needed extensive assistance of two or more staff members to move in the bed.
-He/she had a medically complex condition.
-He/she was at risk for pressure sores.
-He/she had two Stage III pressure sores.
Record review of the facility's Immunization Report, date range 4/1/22 to 4/30/23 showed no documentation the first or second TB tests had been administered.
9b. Record review of the facility's policy, Wound Care, dated October 2010 showed:
-Verify physician's order for the procedure.
-Assemble the equipment and supplies as needed.
-Remove the dry gauze.
-Apply treatment as indicated.
-Dress the wound.
-Remove the disposable cloth and discard into the designated container.
Record review of the resident's April 2023 Physician's Order Sheet showed:
-Cleanse his/her left buttock with wound cleanser (a rinsing solution used to remove foreign materials from a wound) and pat dry.
-Apply barrier cream (a cream used to fight against body fluids) and cover with boarder foam (a highly absorbent foam dressing), daily, dated 4/19/23.
-Cleanse the resident's right buttock with wound cleanser.
-Apply gentamicin (medication used to treat serious infections) to wound bed.
-Pack with calcium alginate rope.
-Cover with bordered gauze to have been changed daily, dated 4/7/23.
Observation on 4/19/23 at 9:30 A.M. of Resident #23's wound care with Licensed Practical Nurse (LPN) A showed:
-The resident had two areas on his/her upper buttocks that were Stage III pressure wounds.
-Wound #1 to the resident's left buttock area was area was 2.5 inches long and was actively bleeding.
-Wound #2 to the resident's right buttock area was a 1 inch long Stage IV circular wound packed with calcium alginate (a soft absorbent dressing made from seaweed used in wound care) rope.
-The nurse took the soiled dressings off of both the resident's wounds.
-The calcium alginate fell out of wound #2.
-The nurse used a 4 inch gauze to wipe the blood off of the bleeding wound, wound #1.
-The Nurse stuffed the bloody gauze into wound #2.
-The Nurse finished dressing wound #1.
-The Nurse took the bloody dressing out of wound #2 and finished dressing it.
During an interview on 4/19/23 at 9:50 A.M. LPN A said:
-He/she did not realize that he/she had wiped the blood off of one wound and inserted it into the other wound.
-The dressing had fallen out of the second wound and stuffed the bloody gauze into the wound.
-He/she should not have put a bloody gauze into a different wound.
During an interview on 4/26/23 at 2:02 P.M. LPN B said:
-The facility has a wound nurse who usually does wound care.
-You should never put a soiled or bloody gauze into another wound.
-Once an area was wiped, the bloody gauze should have been thrown away.
During an interview on 4/26/23 at 3:45 P.M. the acting DON said:
-The regular wound care nurse had been out sick.
-A dirty/bloody gauze should never been put in a different wound.
-It could cause contamination.
-There has not been education done with the staff on wound care lately.
-The DON was ultimately responsible for ensuring wound care was done in a sanitary manner.
Based on observation, interview, and record review, the facility failed to meet all the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility; the facility failed to follow their policy to complete testing to screen new employees and residents for tuberculosis (TB- a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for ten out of ten sampled new employees and for five out of five residents (Residents #35, #203, #23, #88 and #79) sampled for TB screening, and to provide sanitary wound care for one sampled resident (Resident #23) out of two sampled residents sampled for wound care. This practice had the potential to affect all residents, employees and visitors to the facility. The facility census was 105 residents.
1. Record review of the facility's water-borne pathogen program with the policies Legionella Surveillance and Detection and Legionella Water Management Program, provided by the Administrator, showed an educational, 4-page document, last revised in July 2017 by the online company from where it was downloaded, that outlined how to implement such a prevention program and mentioned some CMS requirements, but contained no completed facility-specific documentation on those requirements such as, but not limited to:
-There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.
-There was no schematic or diagram of the facility's complete water system with a written explanation of the water flow throughout the facility.
-There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other waterborne pathogens.
-There was no program and/or flow chart that identified and indicated facility-specific potential risk areas of growth within the building with assessments of each individual area's potential risk level.
-There were no written facility-specific interventions or action plans for when testing protocols and acceptable ranges for control limits are not met.
-There was no documentation of any site log book being maintained with any dated cleanings, sanitizing, descaling, and inspections mentioned.
-On the first page of the second policy mentioned above, at point #2.d., it stated that the water management team would include the Director of Maintenance (DOM).
Observations during the kitchen inspection on 4/17/23 between 9:03 A.M. and 9:47 A.M. showed a three-sink area, a double sink, a wall-mounted sink for hand washing, a chemical dish-washing machine, and an ice machine.
Observations during the Life Safety Code (LSC) facility non-resident room inspections with the Administrator and DOM on 4/18/23 between 11:01 A.M. and 1:43 P.M. showed the following:
-There was a facility-wide fire sprinkler system.
-In the Soiled Utility room by resident room [ROOM NUMBER] there was a floor mounted mop hopper sink with brown residue around the upper water line and in the trap at the bottom indicating it had not been flushed in a while.
-In the Soiled Utility room by resident room [ROOM NUMBER] there was a floor mounted mop hopper sink with unknown residue around the inside of the bowl.
-The facility had four shower rooms, a beauty shop with a sink, two public restrooms, and a boiler room in the basement.
Observations during the LSC facility resident room inspections with the DOM on 4/19/23 between 8:53 A.M. and 10:17 A.M. showed the following:
-There were at least 50 double occupancy resident rooms with a sink in each and a shared bathroom for every two rooms.
-There were at least eight single occupancy rooms with their own bathroom and sink.
During an interview on 4/20/23 at 1:19 P.M. the DOM said that he/she had not been assigned any duties regarding any water-borne pathogen prevention program.
During an interview on 4/21/23 at 10:35 A.M. the Administrator said:
-He/she was aware of CMS's requirements for a water-borne pathogen prevention program, including a diagram of the plumbing, a written flow chart to identify potential risk areas, and interventions with testing protocols.
-The program should be facility-specific.
5. Record review of Resident # 203's admission record showed he/she admitted on [DATE] with the following diagnoses:
-Sacral region (area at base of spinal column and top of pelvic bones) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer.
-Proteus mirabilis morganii (a bacteria found in feces of humans and other mammals) infection.
Record review of the Resident's Immunization Report, for TB screening showed:
-Received the first step of the Mantoux (PPD) on 4/7/23 in the left forearm.
-No record showing result was listed with in the 24 to 48 hour time frame to read the results.
-No record showing he/she received the second step of the Mantoux (PPD) fourteen days later.
2. Record review of the facility's Tuberculosis, Screening for Residents, dated August 2019 showed:
-The facility screened all residents for TB infection and disease.
-The admitting nurse would screen referrals for admission and readmission for information regarding exposure to or having symptoms of TB.
-No further instructions on how to screen the residents was included in the policy.
Record review of the Long Term Care Infection Prevention and Control Manual, Chapter 5, Vaccinations and TB testing, created by the Quality Improvement Program for Missouri (QIPMO), dated February 2022 and the Missouri Department of Health rule 19 CSR 20-20.100 dated 2/28/22 showed:
-Paragraph two:
--Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a Mantoux (a test for immunity to tuberculosis using intradermal injection of tuberculin) purified protein derivative (PPD) two-step TB skin tests (TST)s.
--If the initial test is negative, zero to nine millimeters (mm), the second test, which can be given after admission, should be given one to three weeks later.
--Documentation of chest X-ray evidence ruling out TB disease within one month prior to admission, along with an evaluation to rule out signs and symptoms compatible with infectious TB, may be accepted by the facility on an interim basis until the Mantoux PPD two-step TST is completed.
-Paragraph three:
-All new long-term care facility employees who work ten or more hours per week should have the first of two TST within one month prior to starting employment in the facility.
-The results of the TSTs should be read within 48-72 hours from administration.
-If the initial TST result is zero to nine mm induration, the second test should be administered as soon as possible within three weeks after employment begins, unless documentation is provided indicating a two-step TST was completed in the past and at least one subsequent annual test within the past year.
Record review of TB Screening, Testing and Treatment of U.S. Health Care Personnel dated 8/30/22 on the Center for Disease Control and Prevention's website showed instructions to repeat a TST within one to three weeks after an initial negative TST.
3. Record review of the facility's Employee Tuberculosis Screening policy dated March 2021 showed:
-Each newly hired employee was to be screened for TB prior to hire.
-Screening included a baseline test, individual risk assessment and symptom evaluation.
-If the baseline test was negative and the individual risk assessment indicated no risk factors for acquiring TB, then no additional screening was indicated.
-If the baseline test was positive but the risk assessment was negative and the individual was symptomatic, a second test was conducted.
Record review of the facility's list of employees hired since the facility's last annual survey showed:
-Employee A was hired on 2/21/23.
-Employee B was hired on 8/1/23.
-Employee C was hired on 3/6/23.
-Employee D was hired on 4/13/23.
-Employee E was hired on 1/9/23.
-Employee F was hired on 2/7/23.
-Employee G was hired on 2/7/23.
-Employee H was hired on 1/12/23.
-Employee J was hired on 1/24/23.
-Employee K was hired on 12/14/22.
During an interview on 4/26/23 at 3:44 P.M. with the Acting DON, the Administrator and the MDS Coordinator showed:
-The MDS Coordinator said:
--They were not able to find the employee TB screenings for new employees.
--A two-step TST was required for employees.
--The first TST was supposed to be administered prior to hire.
--The two-step TSTs were supposed to be administered 14 days apart from the first.
--If employees didn't have a TST in the past year, they were supposed to do a two-step TST.
--The previous DON (who had been gone for about two weeks) was responsible for doing the the employee two-step TSTs and tracking them.
--They were not able to find the employee TB screenings for the ten employees sampled.
4. Record review of Resident #35's entry tracking form showed the resident was admitted to the facility on [DATE].
Record review of the resident's immunization tab showed:
-The resident received a step one of a two step TST on 8/16/21 (it was not documented whether this was the administration date or the reading date), TB 2 Step Mantoux Skin Test (Step 1) 8/16/2021 Historical.
-There was no documentation regarding the results of the first TST.
-There was no documentation of an annual TB screening.
Record review of the resident's historical immunization report printed on 4/24/23 showed the following historical data:
-The resident received a one-step and a two-step but it did not have any dates of when they were administered and read and what the results were.
-The resident had a TB risk assessment completed but it did not have a date or the results.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped with a complete, functioning c...
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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 be adequately equipped with a complete, functioning call light system throughout the facility to ensure the ability to meet the residents' needs in a timely manner. This deficient practice had the potential to affect all residents who resided in the facility. The facility census was 105 residents with a licensed capacity for 120 residents at the time of the survey.
Record review of the facility's emergency preparedness plan in a binder entitled Emergency Operations Plan, obtained from the west nurse station and last revised on 1/7/22, on page #30 with the heading Power Outage, showed there was no policy or procedural plan for an alternate method (for example, bells, whistles, or flashlights) for residents to contact staff to have their needs met in the event of a power outage to the building.
1. Observations during the facility non-resident room inspections with the Administrator and Director of Maintenance (DOM) on 4/18/23 between 11:01 A.M. and 1:43 P.M. showed the following:
-The call light for the shower room near resident room [ROOM NUMBER] did not illuminate the corridor call light indicator above the door when it was activated from within.
-The call light for the shower room near resident room [ROOM NUMBER] did not illuminate the corridor call light indicator above the door when it was activated from within.
During an interview on 4/18/23 at 11:47 A.M., the Administrator said the following:
-Some corridor call light indicators worked, some did not.
-They tried fixing the current system, but it was not completed.
-The plan to switch over to a pager system is in the financing process.
Observations during the facility inspection on 4/18/23 at 2:01 P.M. showed that in resident room [ROOM NUMBER] there was no access to a call light cord for bed #2.
Observations during the facility room-by-room inspections with the Director of Maintenance (DOM) on 4/19/23 between 8:53 A.M. and 10:17 A.M. showed the following:
-There were at least 50 double occupancy resident rooms with two call light buttons in each.
-There were at least eight single occupancy rooms with one call light button in each.
During an interview on 4/20/23 at 1:19 P.M. the DOM said they were getting bids from contractors to get all the corridor call light indicators hooked into the system.
Observations during the facility inspection on 4/21/23 at 6:04 A.M. showed that in resident room [ROOM NUMBER] the call light button for bed #1 did not activate the corridor call light indicator.
During an interview on 4/21/23 at 10:35 A.M. the Administrator said the following:
-If the call light corridor indicators were not working staff would have to be at the nurse station to see the monitor to know one was activated.
-The monitor also beeps after five minutes.
-Only about five call light corridor indicators work in the whole facility.
MO00215876
Feb 2023
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #25 and #30) w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #25 and #30) were free from abuse, out of 10 sampled residents. On 2/10/23 Resident #26 struck Resident #25 multiple times on the top of his/her head with a metal object resulting in Resident #25 sustaining a laceration to the top of his/her head in the scalp area, laceration to his/her left ear and abrasion to his/her right elbow. On 2/5/23 Resident #30 was shoved five times by Certified Nurses Aide (CNA) C. The facility census was 113 residents.
The Administrator was notified on 2/14/23 at 1:00 P.M., of the Immediate Jeopardy (IJ) which began on 2/10/23. The IJ was removed on 2/15/23, as confirmed by surveyor onsite verification.
Record review of the facility's policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed:
-All residents had the right to be free from abuse, neglect, exploitation, and misappropriation.
-All residents were to have been protected from abuse by facility staff, other residents, consultants, volunteers, agency staff, family members, legal representatives, friends, visitors, and any other individual.
-The facility was obligated to ensure there was adequate staffing and oversight/supervision to prevent burnout, stressful working situations and high turnover rates.
-All facility staff were to have been trained on abuse prevention, identification, reporting, stress management, and handling verbally and physically aggressive resident behavior.
-The facility was to establish and maintain a culture of compassion and caring for all residents and in particular, those with behavioral, cognitive or emotional problems.
1. Record review of Resident #25's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Alcohol abuse.
-Depression.
Record review of the resident's nursing care plan, dated 5/24/21, showed:
-He/she had a behavior problem related to refusing to abide by the facility policies in regards to smoking times, refusing medications, refusing skin checks and threatening to get facility staff fired.
-He/she was to have fewer episodes of behaviors through the next review period.
-The facility staff were to anticipate and meet his/her needs.
-The facility staff were to document all refusals and behaviors.
-The facility staff were to reinforce and redirect him/her regarding the facility policies.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility staff and used for care planning), dated 1/21/23, showed:
-Was cognitively intact.
-Had issues with being depressed, sleeping too much, changes in eating habits, little interest in doing things, feelings of being better off dead, feeling bad about himself/herself, being tired with little energy and feeling as though he/she let his/her family down, from several days to nearly every day of the past 14 days.
-Had no behaviors.
-Was independent with all cares except for dressing and toileting where he/she needed supervision of one staff member.
Record review of Resident #26's admission MDS, dated [DATE], showed he/she:
-Was cognitively intact.
-Had no issues with mood.
-Had no issues with negative behaviors.
-Was independent with daily personal cares.
Record review of the resident's nursing care plan, dated 11/16/22, showed:
-He/she had the potential for mood problems related to bi-polar disorder.
-He/she would show happier, calmer appearance with no signs of depression, anxiety or sadness.
-The facility staff were to assist him/her in developing a program of activities that was meaningful and of interest.
-The facility staff were to reinforce his/her strengths, encourage/reinforce positive coping skills.
-The facility staff were to obtain a behavioral health consult as needed.
An observation of video surveillance, dated 2/10/23, showed:
-At 7:37.06 P.M., Resident #26 was seen wheeling out of his/her room in his/her wheelchair holding what appears to be a reacher (an assistive device utilized for reaching items placed overhead or on the floor by individuals with arthritis, post-surgical total joint replacement, spinal injuries and more) in his/her left hand.
-The resident wheeled up the hall and around in circles waving the reacher in his/her left hand.
-At 7:37.09 P.M., Resident #26 went back into his/her room.
-At 7:37.38 P.M., Resident #25 came out of his/her room wheeling in a wheelchair, covered in blood all the way down his/her chest, and holding a reacher in his/her right hand.
-Resident #26 was then seen with a staff member at 7:38-7:48 P.M., holding what appeared to be a metal club in his/her left hand.
Record review of the facility Suspected Abuse Investigation, dated 2/10/23 at 8:30 P.M. through 2/15/23 at 3:00 P.M., showed:
-On 2/10/23 at approximately 7:15 P.M., Resident #26 entered Resident #25's room that they shared as roommates.
-Resident #26 began to scream at Resident #25, who was sleeping at the time.
-Resident #26 picked up a long handled reacher and began to strike Resident #25.
-Resident #26 then picked up another object and attempted to continue striking Resident #25.
-Resident #25 was able to get into the hallway and staff immediately separated the two residents.
-Resident #26 was taken outside while Resident #25 was attended to by facility nursing staff inside the facility.
-Police arrived and wrote Resident #26 a summons.
-Emergency Medical Services (EMS) took Resident #25 to the hospital for evaluation and treatment and returned later on that same night.
-Resident #26 was taken to the hospital on a psychiatric hold.
-The hospital was planning on looking for more appropriate long term placement for Resident #26.
-Resident #25 had mild to moderate pain, a few small lacerations and a few small bruises, but was not fearful of any of the residents other than Resident #26.
-All appropriate entities and persons were notified of the incident.
-Record review of Resident #26's Statement/Administrator Interview, dated 2/10/23, showed:
--When the Administrator approached Resident #26, he/she was outside.
--When asked what happened, Resident #26 stated, I hit the mother fucker because he/she stole my cell phone charger.
--Resident #26 had a beer with him/her which was confiscated and emptied.
--The Administrator educated the resident that any type of abuse to another resident would not be tolerated, but Resident #26 remained belligerent.
--The resident did agree to go to the hospital on a psychiatric hold upon the Administrator's request for the safety of the facility residents.
-Record review of Resident #9's Statement/Administrator Interview, dated 2/10/23, showed:
--He/she smoked a cigarette with Resident #26 just prior to the incident.
--Resident #26 appeared calm and visited with the group outside.
--The group came in and was hanging out outside of Resident #26's room to continue to visit.
--Resident #26 then went inside of his/her room and began to scream at his/her roommate (Resident #25).
--Resident #26 picked up a long handled reacher and began to strike Resident #25 who was in his/her bed sleeping.
--Resident #25 was able to get up and out into the hallway while Resident #26 continued to scream.
--Staff intervened and the police were called.
-Record review of Resident #29's Statement/Administrator Interview, dated 2/10/23, showed:
--Resident #26 was outside with a group of residents smoking cigarettes and visiting.
--The group came inside and was sitting in the hallway outside of Resident #26's room.
--Resident #26 entered his/her room and began to scream at Resident #25 who was sleeping in his/her bed.
--Resident #26 picked up a long handled reacher and began to strike Resident #25 with it.
--Resident #25 managed to get into his/her wheelchair and exit the room where the facility staff separated the two residents.
--The police were called and Certified Nurses Aide (CNA) A took Resident #26 outside to separate the two residents until the police arrived.
-Record review of Resident #25's Statement/Administrator Interview, dated 2/11/23, showed:
--He/she was interviewed after returning back to the facility from the hospital.
--He/she and Resident #26 had no prior confrontations and he/she was not expecting anything like the incident to happen.
--He/she was asleep in his/her room that he/he shared with Resident #26.
--He/she was awakened by Resident #26 screaming at him/her.
--Resident #26 then grabbed a long handled reacher and began to strike him/her.
--Resident #26 then grabbed another object and hit him/her with that as well.
--Resident #25 was able to get into his/her wheelchair and into the hallway where the facility staff intervened.
--Resident #26 was taken outside and separated from him/her by his/her CNA A.
--Resident #25 was bleeding so he/she was sent to the hospital.
-Record review of Resident #25's Licensed Nurse Skin Observation, dated 2/11/23 at 6:35 P.M., showed:
--He/she had a laceration on his/her scalp measuring 3.0 centimeters (cm) by 2.0 cm.
-He/she also had a laceration to his/her left ear which was 2.5 cm in length.
During an interview on 2/11/23 at 3:50 P.M., Licensed Practical Nurse (LPN) C said:
-Resident #25 had returned from the hospital with diagnosis of head injury, the facility was waiting on the computerized tomography (CT) scan (combines a series of X-ray images taken from different angles around your body).
-Resident #26 remained in the hospital on a psychiatric hold.
Observation on 2/11/23 at 4:04 P.M., showed:
-Resident #25 had an abrasion to the bridge of his/her nose.
-Dark bruising in the inside corners of both eyes.
-His/her right elbow had a small abrasion.
-His/her left ear had a laceration across the top with bruising behind the ear and moving down his/her neck.
-His/her scalp area on the front lobe had a laceration, caked in a dried reddish substance.
During an interview on 2/11/23 at 4:05 P.M., Resident #25 said:
-He/she had awakened from sleep in his/her bed to Resident #26 hitting him/her with a reacher.
-Resident #26 used to carry the reacher for protection when he/she was homeless.
-He/she had no idea why Resident #26 had attacked him/her.
-Resident #26 had went berserk and tried to kill him/her.
-Resident #26 had even thrown his/her wheelchair upside down.
-Resident #26 was not going to stop.
-He/she yelled for help.
-He/she told the police he/she wanted to press charges.
-He/she was hurting so bad.
During an observation and interview on 2/11/23 at 4:29 P.M., the Director of Nursing (DON) assessment of Resident #25 showed:
-He/she had a laceration on the front left forehead on his/her scalp area.
-The DON indicated the laceration on his/her forehead was open about 1 1/2 cm by 4 cm long.
-He/she had bruising to both inner corners of each of his/her eyes and the bridge of his/her nose.
-The back of the resident's left ear had bruising and a laceration on top of his/her ear with bruising down the back of his/her ear.
-The DON indicated the laceration on the resident's ear was about 6 cm long by 1 cm wide.
-He/she also had an abrasion to his/her right elbow.
-The DON indicated the resident's elbow was tender and soft to the touch.
Record review of the Resident #29's quarterly MDS, dated [DATE] showed he/she:
-Was moderately cognitively intact.
During an interview on 2/11/23 at 4:12 P.M., Resident #29 said:
-He/she, Resident #9, and Resident #26 were out on the smoke deck and had just come in.
-Resident #26 returned to his/her room directly in front of the smoke door where they had been visiting while inside.
-He/she heard yelling out of Resident #25 and Resident #26's room.
-He/she opened the door.
-He/she saw Resident #26 hitting Resident #25 while Resident #25 was in bed.
-Resident #26 was using an object that looked like a pole.
-He/she described it as boom, boom, boom.
-He/she and Resident #9 yelled for help.
Record review of Resident #9's quarterly MDS, dated [DATE], showed he/she:
-Was cognitively intact.
During an interview on 2/14/23 at 10:00 A.M., Resident #9 said:
-He/she saw Resident #26 beating up Resident #25 with what looked like a Billy club.
-He/she went out into the hallway to yell for help.
-It didn't take long at all for the staff to come running to separate the residents.
-He/she didn't know Resident #26 very well as he/she was new.
-He/she was just coming down the hall, heard yelling and saw the beating occurring.
-He/she had no idea why.
-There was a lot of blood so he/she was glad the staff was quick.
During an interview on 2/14/23 at 9:25 A.M., LPN B said:
-He/she was completing medication pass on the other end of the [NAME] Hall near the nursing station, when he/she heard yelling and recognized it as Resident #9's voice.
-He/she heard Resident #9 and Resident #29 yelling help, hurry up.
-He/she and CNA A hurried down the hallway.
-Resident #26 was in the hallway yelling, screaming and swinging a metal pole that extended over his/her head in the hallway directly in front of Resident #25 and Resident #26's room.
-Upon arrival, Resident #25 rolled out of his/her room covered in blood from the top of his/her head to his/her navel area.
-Resident #26 was yelling he/she would do it again.
-CNA A took Resident #26 outside.
-He/she attended to Resident #25.
-Resident #9 and Resident #29 said they had both heard voices in Resident #25 and Resident #26's room.
-Resident #9 and Resident #29 said they opened the door and began to scream for help.
-Resident #25 was in bed asleep.
-Both Resident #25 and Resident #26 were transported to the hospital.
During an interview on 2/14/23 at 9:25 A.M., the Medical Director said:
-He/she had never had any issues with Resident #26.
-He/she never knew the resident to be violent with anyone.
During an interview on 2/14/23 at 10:20 A.M., CNA A said:
-He/she was in the hallway and overheard yelling for help.
-He/she ran down the hall and found Resident #26 yelling at and hitting Resident #25 with some sort of weapon.
-He/she helped the nurse intervene and took Resident #26 outside, while the nurse attended to Resident #25's injuries.
-Resident #26 said that Resident #25 stole from him/her so that was why he/she beat him/her up.
During an interview on 2/14/23 at 12:00 P.M., the DON said:
-He/she never knew Resident #26 to be violent.
-He/she was not aware of any behavior issues with him/her prior to this incident.
-He/she had a reacher from the room that he/she used to hit Resident #25 and also had some sort of a metal rod which he/she also used to hit the resident.
During an interview on 2/14/23 at 12:20 P.M., the facility Administrator said:
-He/she was not aware that either resident had any behavior issues, but Resident #26 had not been in the facility for very long.
-He/she was not aware of Resident #25 stealing anything from Resident #26.
-He/she thought that Resident #26 not only used a reacher to strike Resident #25, but also used some sort of metal pole that the resident stated he/she used to defend himself/herself when he/she was homeless on the street.
-He/she heard Resident #25 state that he/she thought that if staff had not come when they did, Resident #26 would have killed him/her.
During an interview on 2/15/23 at 10:00 A.M., Resident #26 said:
-Resident #25 stole from him/her.
-If I see the mother fucker again, I will kill him/her!
-I don't want to go back to that place again and if I do go back there, I will kill the mother fucker!
-He/she used a reacher that was in his/her room.
-He/she never had a metal looking rod that he/she used on Resident #25.
2. Record review of Resident #30's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile).
-Seizures.
Record review of the resident's quarterly MDS, dated [DATE], showed he/she:
-Was cognitively intact.
-Had issues with feeling depressed, trouble falling asleep, staying asleep or sleeping too much, and showed little interest or pleasure in doing things several days per week.
-Had no negative behaviors.
Record review of the resident's Concern/Compliment Form, dated 2/6/23, showed:
-CNA C came into the resident's room on 2/5/23 at at 6:15 A.M., and started going through the resident's closet for no reason.
-When the resident asked CNA C to leave, the CNA said he/she was the cops and did not have to leave.
-CNA C then began pushing the resident.
-The facility Administrator was able to substantiate the concern via facility camera showing the incident did occur.
-CNA C was immediately terminated and the appropriate entities were notified.
Record review of the written statement for CNA C, dated 2/6/23, showed:
-On 2/5/23 at approximately 6:30 A.M., as he/she walked into the resident's room, the resident pushed him/her saying he/she did not want anyone in his/her room.
-The resident then followed him/her out into the hallway and was trying to hit him/her.
-He/she then notified the charge nurse.
-He/she had never seen the resident act that way.
Record review of the facility Staff Interview conducted by the facility Administrator, dated 2/6/23, showed:
-The Administrator called CNA C for a phone interview, but CNA C stated he/she had left a written statement in the DON's mailbox.
-It had been established that CNA C did not notify the charge nurse of the incident.
-When the facility Administrator began to explain to CNA C that he/she was terminated for pushing the resident and it was captured on camera, CNA C immediately hung up the phone.
-When CNA C was called back, he/she stated he/she did not tell anyone because he/she did not want to get in trouble, as he/she did not start the confrontation.
-The facility Administrator then explained to CNA C at no time were staff to retaliate or put their hands on residents in a bad way, to which CNA C hung up the phone.
Record review of the Resident Interview conducted by the facility Administrator, dated 2/6/23 at 8:50 A.M., showed:
-On the morning of 2/5/23, CNA C came into Resident #30's room around 6:15 A.M., and began going through the resident's items in his/her closet.
-The resident asked CNA C to get out of his/her room immediately.
-CNA C refused to leave so the resident got up to chase him/her out of the room.
-Both parties began pushing at each other and the incident finished in the hallway.
-After shoving at each other a few times, the two separated, exchanged words and the resident went back into his/her room.
-No other parties were present to witness the incident.
-The resident stated he/she was fearful of CNA C.
-The facility Administrator reassured the resident that CNA C would not be returning to the facility.
Record review of the facility Suspected Abuse Investigation, dated 2/6/23 at 8:30 A.M. through 2/11/23 at 9:30 A.M., showed:
-CNA C entered Resident #30's room at approximately 6:10 A.M.
-The resident stated CNA C was looking in his/her and his/her roommate's closet and the resident asked CNA C to exit the room.
-When CNA C refused to exit, Resident #30 charged at CNA C and gave him/her a slight push to get him/her out of the room.
-CNA C then turned and could be seen on camera in the doorway shoving Resident #30.
-The video continued to show Resident #30 walking towards CNA C while CNA C continued to shove him/her.
-Resident #30 did not report the incident at the time but instead, slid a paper under the Social Services Director's door with his/her statement.
-CNA C also did not report the incident, but instead placed a statement into the DON's mailbox.
-The incident was reported to the appropriate entities and CNA C was terminated.
-The resident was not injured.
Observation of the video surveillance located in the hallway outside of Resident #30's room on 2/10/23, showed:
-CNA C was seen walking into Resident #30's room on 2/5/23 at 6:11.22 A.M.
-CNA C exited the resident's room at 6:11.43 A.M.
-Resident #30 came into view of the camera, exiting into the hallway at 6:11.47 A.M.
-Resident #30 was pushed by CNA C at 6:11.48 A.M.
-The resident was then seen walking towards CNA C and was pushed a second time at 6:11.54 A.M.
-The resident continued to walk towards CNA C while he/s he was walking backwards, shoving the resident a third time at 6:11.57 A.M.
-The resident was pushed by CNA C a fourth time at 6:12.02 A.M.
-The resident continued to walk towards CNA C who in turn, pushed the resident a fifth time at 6:12.13 A.M., before he/she then exited down the hallway.
During an interview on 2/10/23 at 12:05 P.M., Resident #30 said:
-He/she had never had any issues with this particular CNA in the past.
-Around 6:15 A.M. on 2/5/23, CNA C came into the resident's room and proceeded to nose through the resident and his/her roommate, who was in the hospital at the time, belongings.
-He/she told CNA C to get out of his/her room to which the CNA replied, he/she was the cops.
-The resident knew he/she was not the police, so he/she jumped out of bed, as CNA C began opening up the resident's closet doors.
-He/she once again told the CNA to leave and as he/she exited the room, the resident gave the CNA a little shove and followed him/her out of the room.
-As he/she was walking toward the CNA down the hallway, the CNA began pushing him/her.
-The whole time he/she was walking down the hallway towards CNA C, CNA C was walking backwards saying, bring it on, like he/she wanted to fight.
-He/she then returned to his/her room and put a chair up against the door so no one could get in his/her room.
-He/she was afraid the CNA was going to hit him/her.
-He/she was only afraid of that one CNA so now that he/she knows the CNA was gone, he/she was no longer fearful.
During a phone interview on 2/10/23 at 1:30 P.M., CNA C said he/she would not answer any questions and hung up the phone.
During an interview on 2/10/23 at 3:00 P.M., the Administrator said:
-He/she was not made aware that anything had occurred with CNA C and Resident #30 until the DON and Social Worker told him/her they each had a note in their offices regarding the incident.
-He/she definitely thought it was an abusive incident.
-He/she had not known this staff member to be abusive or have any disciplinary problems in the past.
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
MO00213645 and MO00213890
Jan 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse for three sampled residents (Res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse for three sampled residents (Resident #1, #15 and #16). On 12/3/22 Resident #2 struck Resident #1 in the face. On 12/25/22 Resident #19 was verbally abusive towards Resident #15 calling him/her slurs and yelling resulting in Resident #19 shoving Resident #16 out of 24 sampled residents. The facility census was 105 residents.
Record review of the facility's undated, revised April 2021, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy showed:
-Residents had the right to be free from abuse, including physical abuse.
-The resident abuse, neglect and exploitation prevention program consisted of a facility-wide commitment and resource allocation to support the following objective:
--Protect residents from abuse by anyone including other residents.
-Protect residents from any further harm during investigations.
Record review of the facility's undated, revised December 2016, Resident-to-Resident Altercations Policy showed:
-All altercations, including those that might represent resident-to-resident abuse, should be investigated and reported to the nursing supervisor, the director of nursing services and the administrator.
-Facility staff would monitor residents for aggressive/inappropriate behavior toward other residents, family members, visitors or the staff.
1. Record review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE].
Record review of Resident #1's diagnosis report dated 12/12/22 showed he/she had the following diagnoses:
-Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety (changes to memory, thinking and behavior resulting from conditions that affect the blood vessels in the brain)
- Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety)
Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) showed his/her MDS had not been completed.
Record review of Resident #1's undated care plan showed he/she had impaired cognitive function/dementia or impaired thought processes, difficulty making decisions and long term memory loss.
Record review of Resident #1's Brief Interview for Mental Status (BIMS) dated 10/1/22 showed he/she had a BIMS of 3, indicating he/she had severe cognitive impairment.
Record review of Resident #2's Preadmission Screening and Resident Review (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment) dated 9/19/19 showed:
-He/she was diagnosed with Anoxic Brain Damage (harm to the brain due to lack of oxygen).
-He/she had occasional episodes of hitting other residents.
Record review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety (changes to memory, thinking and behavior resulting from conditions that affect the blood vessels in the brain)
-Disorder of Brain, Unspecified (disturbance of normal functioning of the brain)
Record review of Resident #2's admission MDS dated [DATE] showed the Section C (Cognitive Patterns) portion was not completed with no information about his/her BIMS.
Record review of Resident #2's undated care plan showed he/she had the potential to be physically aggressive related to history of harm to others and poor impulse control.
Record review of the facility's undated investigation showed:
-On 12/3/22 Resident #2 hit a resident in the face as he/she had walked past Resident #2.
-Statement dated 12/3/22 from Certified Nurses Aide (CNA) A, showed he/she was passing trays and Resident #1 was following him/her around. Resident #2 stood up and hit the other resident in the face.
During an interview on 12/12/22 at 10:46 A.M., Resident #1 said he/she only remembered someone hit him/her on the side of his/her head.
During an interview on 12/9/22 at 12:43 P.M., CNA A said:
-He/she was serving food and drinks in the dining room and Resident #1 was following him/her around.
-Resident #2 stood up and started hitting Resident #1 in the face.
-He/she told Resident #2 that he/she couldn't hit Resident #1.
-Resident #2 then tried to hit him/her.
-He/she had seen Resident #2 try to hit other residents and then sit back in his/her chair like nothing happened.
-Resident #2 knew what he/she was doing.
During an interview on 12/13/22 at 12:29 P.M., the Physician said:
-Resident #2 was impulsive.
-The facility had reported Resident #2 hit Resident #1.
-The last time he/she saw Resident #2, he/she was thinking of increasing the resident's dose of Depakote (divalproex sodium-an anticonvulsant used to treat seizures, mental/mood disorders and to prevent migraine headaches).
-He/she would expect the facility to separate the residents, put them on room checks and do some kind of behavior modification.
-He/she would expect the facility to notify him/her or the Psychiatrist.
During an interview on 12/16/22 at 4:09 P.M., the Regional Support Specialist and Director of Nursing (DON) said:
-Resident #2 was on the list for a Psychiatric consult.
-Resident #2 refused to go to the hospital after he/she hit Resident #1.
-They started monitoring Resident #2's behaviors to identify what may be triggering him/her.
-Resident #2 was on fifteen minute checks in his/her room after he/she hit Resident #1.
-There was documentation from the hospital that Resident #1 was using racial slurs there as well.
-Resident #2 had reported that he/she hit Resident #1 because Resident #1 called him/her a racial slur.
-Resident #1 could have said the racial slur in such a way that CNA A did not hear what he/she said.
-Resident #2 and Resident #1 have been kept separate and staff must be with the residents if they are in a common area, such as the dining room, together.
-Resident #1 hit a different resident prior to the Regional Support Specialist and the DON starting their positions at the facility.
2. Record review of Resident #15's facility admission Record showed he/she was admitted on [DATE] with a diagnosis of alcohol abuse.
Record review of Resident #15's annual MDS dated [DATE] showed he/she:
-Was cognitively intact.
-Had minimal issues with his/her mood and no negative behaviors.
-Was independent with bed mobility, transferring, walking, personal hygiene, eating, toileting, bathing and dressing.
Record review of Resident #15's Nursing Care Plan dated 1/3/22 showed:
-He/she had issues with his/her psychological well-being due to ineffective coping skills.
-He/she was to show effective coping skills by the review period.
-The facility staff was to encourage him/her to set realistic goals.
-The facility staff was to encourage him/her to make his/her own decisions.
-The facility staff was to encourage him/her to increase social relationships.
-The facility staff was to assist him/her to identify problems that cannot be controlled.
-The facility staff was to support him/her to identify potential solutions to problems.
-When conflict arises, the facility staff was to remove the resident to a calm, safe environment and allow him/her to share their feelings.
Record review of Resident #16's facility admission Record showed he/she was admitted to the facility on [DATE] with a diagnosis of hallucinogen abuse with intoxication (the effects of using awareness altering drugs to the point of causing hallucinations and other severe reactions).
Record review of Resident #16's admission MDS dated [DATE] showed:
-He/she was cognitively intact.
-He/she had no issues with mood and no negative behaviors.
-He/she required supervision or oversight of one facility staff member for bed mobility, walking, eating and personal hygiene.
-He/she required limited assistance of one staff member for transferring, dressing, toileting and bathing.
Record review of Resident #16's facility nursing care plan dated 12/29/22 showed:
-He/she could become verbally abusive, physically abusive or agitated related to active drug use.
-He/she was to have fewer episodes of verbal/physical aggression and agitation daily during the review period.
-The facility staff was to administer medications as order and documents their effectiveness.
-The facility staff was to assist him/her to develop more appropriate methods of coping and interacting with others, and encourage him/her to express his/he feelings appropriately.
-The facility staff was to educate him/her/family/caregivers on successful coping and interactions strategies, while encouraging the resident to and actively support the family/caregivers.
-He/she was to have been sent to the hospital for psych evaluation and treatment as indicated.
-He/she was to allow facility staff to search his/her belongings for drugs and drug related items if the resident appears to be under the influence of illicit substances.
-The facility staff was to check on the resident every 15 minutes to ensure safety.
Record review of Resident #19's facility admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Schizophrenia-(schizophrenia (a psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday life)
-Bi-polar disorder with current manic phase, severe-(a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
-Psychoactive substance abuse (a group of drugs which affects how the brain works causing changes in mood, awareness, thoughts and feelings).
Record review of Resident #19's undated nursing care plan showed:
-He/she had the potential be both verbally and physically aggressive related to anger and poor impulse control.
-He/she was to demonstrate effective coping skills, not harm himself/herself or others, verbalize understanding the need to control his/her behaviors and seek out staff when his/her agitation occurs.
-His/her triggers were not specified as the triggers and behaviors were left blank in the care plan.
-The facility staff was to administer medication as prescribed.
-The facility staff was to analyze the times of day, places, circumstances, triggers (unspecified) and what de-escalated (unspecified) him/her and document.
-The facility staff was to address any contributing sensory deficits.
-The facility staff was to consult with psychiatry as needed.
-The facility staff was to assess his/her coping skills and support system.
-The facility staff was to allow time for him/her to express himself/herself and his/her feelings towards the situation.
Record review of Resident #19's quarterly MDS dated [DATE] showed:
-He/she was cognitively intact.
-He/she had issues with being depressed/hopeless and not eating or over eating one to several days a week.
-He/she exhibited no negative behaviors.
-He/she needed limited assistance of one facility staff member for bed mobility, transferring, personal hygiene, toileting, eating and bathing.
Record review of Resident #19's nurse's notes dated 12/25/22 at 10:27 A.M., showed:
-He/she was very agitated throughout the day.
-He/she believed other residents had stolen items from him/her.
-Had frequently argued with other residents throughout the shift.
-He/she became out of control, unable to be re-directed by facility staff and approached Resident #16 at 9:40 A.M., arguing with him/her as he/she had done multiple times during the shift.
-He/she then approached Resident #16 and pushed him/her down.
-Facility staff intervened in each of the situations and no injuries occurred.
-The police was called and came to the facility to obtain statements from the residents and staff.
-Resident #19 was arrested and taken to the local jail at 10:10 A.M.
Record review of the undated/untimed Facility Investigation showed:
-On the morning on 12/25/22, Resident #16 started aggravating other residents by threatening them and calling them names.
-Resident #16 told Resident #15 to shut up and suck his/her dick .
-When Resident #19 was coming inside from smoking, he/she called Resident #15 a bitch.
-Resident #19 grabbed Resident #16 by the coat and told the resident to leave him/her alone and threatened harm to the resident if he/she did not leave him/her alone.
-Resident #19 began yelling Resident #15 and called him/her a fat black bitch.
-Facility staff were unable to calm Resident #19 down, the DON was notified who instructed them immediately to call police if they could not get the resident under control.
-Police arrived shortly after, interviewed staff and residents.
-The police handcuffed Resident #19 and took him to jail, where he/she posted bond and returned to the facility.
-Upon return to the facility, staff were instructed to place him/her on 15 minute checks.
During an interview on 12/26/22 at 5:48 P.M., Resident #15's Family Member A said:
-On 12/25/22 Resident #19 had yelled at and called Resident #15 a bitch.
-Resident #15 said he/she will probably stay barricaded in his/her room and eat there because he/she was afraid to go out of his/her room because of Resident #19.
-Family Member A had decided he/she would pick Resident #15 up and take his/her home; but Resident #19 was arrested instead.
-Resident #19 was back at the facility and he/she should not be there and needed to be removed.
During an interview on 12/26/22 at 12:12 P.M., Resident #15 said:
-Resident #19 was in his/her face yelling and called him/her a fucking black bitch.
-He/she had called Family Member A and was upset.
-He/she stated that Resident #19 was scary.
During an interview on 12/26/22 at 12:48 P.M., Resident #16 said:
-Resident #19 had accused him/her of stealing cologne from him/her.
-The resident then grabbed him/her and shoved him/her.
-The facility staff called the police and the resident was taken to jail but had since returned to the facility.
-He/she was not afraid of Resident #19.
During an interview on 12/26/22 at 1:06 P.M., the DON said:
-On 12/25/22, Resident #19 accused Resident #16 stealing from him/her and the resident proceeded to touch Resident #16 on his/her shoulder, cursing at him/her.
-The facility staff called the police and Resident #19 was arrested and taken to jail.
-Resident #19 posted bond, was released from jail, evaluated at a mental health facility and returned to the facility later the same evening.
-Resident #19 said he/she planned on staying away from Resident #16.
During an interview on 12/26/22 at 1:17 P.M., Resident #19 said:
-Resident #16 accused him/her of stealing, cursed at him/her and touched him/her on the back.
-The staff called the police and he/she had to go to jail and then to a mental health place.
-He/she planned on just staying away from Resident #16.
During an interview on 1/4/23 at 1:30 P.M., the Administrator said:
-He/she had only been the Administrator for a few days so he/she was still learning.
-He/she was working on some additional education for the staff.
-He/she would have expected staff to try their best to de-escalate staff when needed.
MO00210740, MO00211701
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
PASARR Coordination
(Tag F0644)
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 incorporate information from a Preadmission Screening and Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to incorporate information from a Preadmission Screening and Resident Review (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment) into the care plan for one sampled resident (Resident #2) out of 24 sampled residents. The facility census was 105 residents.
1. Record review of Resident #2's PASRR dated 9/19/19 showed he/she had occasional episodes of hitting other residents.
Record review of the resident's face sheet showed the resident was admitted to the facility on [DATE].
Record review of the resident's admission Minumun Data Set (MDS a federally mandated assessment instrument completed by facility staff for care planning)
dated 2/9/22 showed:
-Section C (Cognitive Patterns) portion was not completed with no information about his/her Brief Interview of Mental Status (BIMS).
-Section E (Behaviors) was completed and noted no behaviors.
Record review of the resident's undated care plan showed:
-The problem identified:
--He/she had the potential to be physically aggressive related to history of harm to others and poor impulse control, initialed 11/10/22.
-The desired goals:
--He/she would demonstrate effective coping skills.
--He/she would not harm self or others.
--He/she would seek out staff/caregiver when agitation occurred.
-Interventions dated 11/10/22 showed:
--Analyze times of day, places, circumstances, triggers and what de-escalates behavior and document.
--Assess and address for contributing sensory deficits.
--Communication: provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior and encourage seeking out of staff member when agitated.
--Give the resident as many choices as possible about care and activities.
--Psychiatric/Psychogeriatric consult as indicated.
-Interventions dated 12/6/22 showed:
--Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, paint etc.
--Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others.
--When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later.
Record review of an undated facility investigation showed Resident #2 hit a resident in the face on 10/14/22.
Record review of an undated facility investigation showed Resident #2 hit another resident in the face on 12/3/22.
During an interview on 12/9/22 at 4:45 P.M., Licensed Practical Nurse (LPN) C said he/she had no knowledge of Resident #2 acting out physically against other residents.
During an interview on 12/12/22 at 4:12 P.M., the Director of Nursing (DON) said:
-Care plans were completed by the Interdisciplinary Team (IDT) group.
-Any known behaviors from the PASRR should be included on care plans.
-He/she would have expected that Resident #2's behavior of hitting other residents would be in his/her care plan.
MO00210740
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 ensure bathing was completed at least weekly; and to c...
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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 bathing was completed at least weekly; and to chart weekly baths were given for two sampled residents (Resident #16 and #18) who were dependent on staff for completing Activities of Daily Living (ADL - baths, dressing, eating, and grooming) out of 24 sampled residents. The facility census was 105 residents.
Record review of the facility Activities of Daily Living (ADL) Supporting policy Revised March 2018 showed:
-Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.
-Residents who are unable to carry out ADLs independently in accordance with the plan of care, will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
-Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate the diminishing ADLs are unavoidable.
--Unavoidable decline may occur if he/she refuses care and treatment to restore of maintain functional abilities.
---The resident and or representative had been informed of the risk and benefits of the proposed care or treatment.
---He/she had been offered alternative interventions to minimize further decline,
---The refusal and information had been documented in the resident's medical record.
-A resident's ability to perform ADLs will be measured using a clinical tools, including the Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning).
-Interventions to improve of minimize a resident's functional abilities will be in accordance with the resident's assessment needs, preferences, stated goals and recognized standards of practice.
1. Record review of Resident #16's admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of a malignant neoplasm of upper right lobe of lung (lung cancer).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment completed by facility staff for care planning) dated 11/16/22, showed:
-He/she was cognitively intact.
-He/she needed physical help in part of the bathing activity.
-No behaviors of rejecting of cares.
Record review of the resident's undated Care Plan showed he/she had no care plan for bathing or rejecting/refusing cares.
Observation on 1/3/23 at 2:37 P.M. showed the resident's hair was dirty and unkept.
During an interview on 1/3/23 at 2:37 P.M, the resident said:
-The staff do not offer to give him/her a bath/shower.
-He/she needed help with transferring and undressing for a bath/shower.
-If he/she was offered a bath/shower, he/she would take it because he/she does not know when it will be offered again.
Record review of the resident's Comprehensive Shower Review on 1/4/23, showed:
-The resident did not have any record of ever taking a shower since admission to the facility.
-No record of the resident refusing showers.
2. Record review of Resident #18 admission Record showed he/she was admitted to the facility on [DATE], with the following diagnosis:
-Fracture of base of fifth finger on the left hand.
-Stroke affecting the right dominant side.
Record review of the resident's Care Plan dated 12/17/22, showed no care plan for bathing or rejecting/refusing cares.
Record review of the resident's admission MDS dated [DATE], showed:
-He/she was cognitively intact.
-He/she was totally dependent for bed mobility, transfers, dressing, eating, toileting and baths with the help of two persons.
-No behaviors of rejecting cares.
Record review of the resident's Comprehensive Shower Review dated 12/26/22, showed:
-The resident's skin was okay.
-Not noted if the resident received a shower or bed bath.
Record review of the resident's Nurse's Note dated 12/27/22 at 3:34 P.M., showed he/she received a shower today.
Record review of the resident's Nurse's Note dated 12/31/22 at 5:31 P.M., showed the resident had a bed bath.
Observation on 1/3/23 at 10:16 A.M., showed:
-The resident was sitting up in bed playing a game on his/her tablet and watching television.
-The resident's left hand was in a splint with his/her right hand at his/her side on the bed.
-The resident was well groomed, hair and clothes were clean with no odors at that time.
During an interview on 1/3/23 at 10:16 A. M., the resident said:
-He/she admitted on [DATE] and had a bath on 12/26/22 and a bed bath on 12/31/22.
-The bed bath was given on 12/26/22 after family got upset with the facility staff.
-He/she did not consider a bed bath as a bath and wanted to be taken to the shower room for a shower.
-He/she cannot use his/her right upper and lower extremities at all due to a stroke.
-He/she looked good today because of the bath on 12/26/22.
-He/she did not feel good because he/she had not received baths routinely.
During an interview on 1/4/23 at 8:50 A.M., the Director of Nursing (DON) said:
-The facility did not have any shower sheets for Resident #16 and Resident #18.
-Resident #16 was independent and refused showers quite often.
-Staff would not fill out shower sheets for independent residents or a resident refuses a shower.
-The facility did not use shower aides. The Certified Nursing Assistants (CNA's) were responsible for giving showers and charting if a resident took a shower or refused a shower.
-Residents were to be bathed twice a week.
During an interview on 1/4/23 at 10:11 A.M. CNA C and CNA D said:
-The facility had a bath book that contained the resident's name and the scheduled days the resident's were to take or be given a bath/shower.
-The resident should get a bath/shower two times a week and as needed.
-If a resident refused a bath/shower he/she was to notify the charge nurse.
During an interview on 1/4/23 at 11:50 A.M., admission Coordinator said:
-The residents have not been getting baths/showers for a long time.
-Bathing the residents has been a big problem with the staff not giving the baths/showers or documenting if the bath/shower was given.
-He/she had problems with the staff not giving baths/showers when he/she was acting Administrator and Social Services at the facility.
-The residents should get a bath/shower twice a week on his/her scheduled bath/shower days and as needed.
-The staff should chart in each resident's medical record if a bath/shower was given or if the bath/shower was refused and why it was refused.
MO00211745
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services were provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services were provided so residents can obtain the highest practicable mental and psychosocial well-being for two sampled residents (Resident #16 and Resident #19) out of 24 sampled residents. The facility census was 105 residents.
Requests were made for a Behavior Policy on 12/19/22 and 1/4/23 and the policy was never provided.
Record review of the Facility assessment dated 12/21 through 11/22 showed:
-The purpose of the Facility Assessment was to determine what resources were necessary to take care for residents completely during both day to day operations and emergencies.
-The assessment was to be be used to make decisions about direct care staff needs as well as capabilities to provide services all residents in the facility.
-Using a competency-based approach focused on ensuring that each resident was provided care that allowed the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being.
1. Record review of Resident #16's facility admission Record showed he/she was admitted on [DATE] with a diagnosis of hallucinogen abuse with intoxication (the effects of using awareness altering drugs to the point of causing hallucinations and other severe reactions).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 11/16/22 showed:
-He/she was cognitively intact.
-He/she had no issues with mood and no negative behaviors.
-Required supervision or oversight of one facility staff member for bed mobility, walking, eating and personal hygiene.
-Required limited assistance of one staff member for transferring, dressing, toileting and bathing.
Record review of Resident #16's nurse's notes dated 12/25/22 at 3:25 P.M., showed:
-Earlier in the morning, Resident #16 started aggravating other residents by threatening them, and calling them names.
-He/she called Resident #19 a bitch and continually to verbally harassed Resident #19.
-Eventually Resident #19 had enough so he/she grabbed Resident #16 by the coat and told the resident to leave him/her alone or he/she was going to do something to resident.
-At some point during that time Resident #16 was verbally harassing other residents, Resident #19 became out of control and was unable to be redirected.
-The Director of Nursing (DON) was notified and instructed the staff to call the police.
-The police arrived and took Resident #19 into custody.
Record review of the resident's facility nursing care plan dated 12/29/22 showed:
-He/she could become verbally abusive, physically abusive or agitated related to active drug use.
-He/she was to have fewer episodes of verbal/physical aggression and agitation daily during the review period.
-The facility staff was to administer medications as order and documents their effectiveness.
-The facility staff was to assist him/her to develop more appropriate methods of coping and interacting with others, and encourage him/her to express his/he feelings appropriately.
-The facility staff was to educate him/her/family/caregivers on successful coping and interactions strategies, while encouraging the resident to and actively support the family/caregivers.
-He/she was to have been sent to the hospital for psych evaluation and treatment as indicated.
-He/she was to allow facility staff to search his/her belongings for drugs and drug related items if the resident appears to be under the influence of illicit substances.
-The facility staff was to check on the resident every 15 minutes to ensure safety.
During an interview on 1/4/23 at 10:30 A.M.,, Certified Nurses Aide (CNA) B said:
-When a resident had behaviors, he/she was to try to redirect them.
-If the resident did not de-escalate, he/she was to get help and notify the nurse.
During an interview on 1/4/23 at 11:15 A.M., Licensed Practical Nurse (LPN) B said:
-When a resident became upset, or was having a behavior, staff should try to calm them down.
-If the resident did not calm down, the staff member should try to re-direct the resident.
-If the resident continued to have behaviors, the staff should get extra help.
During an interview on 1/4/23 at 1:40 P.M., the DON said:
-Resident #16 purposefully irritates residents by continually yelling at them, calling them names, and constantly bothering them on purpose.
-Eventually the residents get sick of it and lash out.
-He/she did not know what to do to with Resident #16.
2. Record review of Resident #19's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Schizophrenia (schizophrenia (a psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday life).
-Bi-polar disorder with current manic phase, severe (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
-Psychoactive substance abuse (a group of drugs which affects how the brain works causing changes in mood, awareness, thoughts and feelings).
Record review of the resident's Preadmission Screening and Resident Review (PASRR- a federally required screening tool to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 7/21/22 showed:
-He/she had a serious mental illness which required attention such as every two hours facility staff observations of him/her.
-He/she had serious difficulty adapting to typical changes in circumstances associated with work, school, family or social interactions.
-His/her mental illness caused agitation, withdrawal from situations, self-mutilation, suicidal ideations, gestures, threats or attempts, physical violence or threats, appetite disturbances, delusions, hallucinations, serious loss of interest, tearfulness, irritability, or requiring intervention by mental health or the judicial system.
-He/she had serious difficulty interacting appropriately and communicating effectively with other persons with a possible history of altercations, evictions, unstable employment, fear of strangers, avoidance of interpersonal relationships and social isolation.
-He/she had a history or at least one psychiatric treatment episode and oat least one episode of significant disruption to his/her normal living situation, requiring supportive services.
-He/she had a substance related disorder.
Record review of the resident's undated nursing care plan showed:
-He/she had the potential be both verbally and physically aggressive related to anger and poor impulse control.
-He/she was to demonstrate effective coping skills, not harm himself/herself or others, verbalize understanding the need to control his/her behaviors and seek out staff when his/her agitation occurs.
-His/her triggers were not specified as the triggers and behaviors were left blank in the care plan.
-The facility staff was to administer medication as prescribed.
-The facility staff was to analyze the times of day, places, circumstances, triggers (unspecified) and what de-escalated (unspecified) him/her and document.
-The facility staff was to address any contributing sensory deficits.
-The facility staff was to consult with psychiatry as needed.
-The facility staff was to assess his/her coping skills and support system.
-The facility staff was to allow time for him/her to express himself/herself and his/her feelings towards the situation.
Record review of the resident's quarterly MDS dated [DATE] showed:
-He/she was cognitively intact.
-He/she had issues with being depressed/hopeless and not eating or over eating one to several days a week.
-He/she exhibited no negative behaviors.
-He/she needed limited assistance of one facility staff member for bed mobility, transferring, personal hygiene, toileting, eating and bathing.
Record review of the resident's nurse's notes dated 12/19/22 at 10:14 A.M., showed:
-He/she was walking about in the hallway, talking to himself/herself, throwing his/her arms about.
-He/she was opening up doors in the facility talking to people who were not there.
-He/she was hollering in the hallway, arguing with peers, hitting his/her head on the walls, unable to be redirected by facility staff.
Record review of the resident's nurse's notes dated 12/19/22 at 10:42 A.M., showed the physician was notified and ordered the resident be sent to the hospital for evaluation and treatment related to his/her increased agitation, pacing, arguing, throwing his/her arms about and yelling.
Record review of the resident's nurse's notes dated 12/19/22 at 5:54 P.M., showed he/she returned from the hospital with no new orders having found to have methamphetamines (a potent central nervous system stimulant drug primarily used recreationally) in his/her system.
Record review of the resident's nurse's notes dated 12/25/22 at 10:27 A.M., showed:
-He/she was very agitated throughout the day.
-He/she believed other residents had stolen from him/her.
-Had frequently argued with other residents throughout the shift.
-He/she became out of control, unable to be re-directed by facility staff and approached Resident #16 at 9:40 A.M., arguing with him/her as he/she had done multiple times during the shift.
-He/she then pushed Resident #16 down.
-Facility staff intervened in each of the situations and no injuries had occurred.
-The police was called and came to the facility to obtain statements from the residents and staff.
-Resident #19 was arrested and taken to jail at 10:10 A.M.
Record review of the resident's psychiatric assessment dated [DATE] showed:
-He/she had inappropriate and uncooperative social interactions.
-His/her cognition was worse.
-He/she showed recent verbal agitation such as yelling, screaming, arguing and accusatory behavior.
-He/she had a physical altercation with Resident #16 due to him/her having been in a manic phase and accusatory, he/she required staff redirection and increased monitoring.
-His/her insight and judgement were poor.
Observation on 1/3/23 at 9:15 A.M., showed:
-Resident #19 was in the front lobby area of the facility, screaming at facility staff, stating that his/her ID had been stolen from his/her room.
-He/she was pacing and ringing his/her hands, thrashing about in circles as he/she screamed at facility staff about his/her ID.
During an interview on 1/4/23 at 10:30 A.M., CNA B said:
-No interventions really work for Resident #16 or Resident #19.
-It was impossible to redirect these residents.
-Resident #16 antagonized other residents, calling them names and agitating them and would not stop when told.
-Both residents were very difficult to move away from other residents as they would leave for awhile and then come back and continue aggravating other residents.
During an interview on 1/4/23 at 11:15 A.M., LPN B said:
-Both Resident #16 and #19 were impossible.
-Neither resident redirected well at all.
-The staff have had to call the police for Resident #19 because he/she would not de-escalate.
During an interview on 1/4/23 at 1:40 P.M., the DON said:
-On the 12/25/22 incident, Resident #16 had been yelling, cursing and was simply out of control to the point the staff were afraid he/she was going to harm someone. Resident #19 had just had enough of Resident #16's actions and ended up grabbing him/her by the shirt collar and shoving Resident #16 down.
MO00211701
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to complete Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) assessments for ni...
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Based on interview and record review, the facility failed to complete Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) assessments for nine sampled residents (Resident #1, #3, #4, #5, #6, #7, #8, #11 and #12) out of 24 sampled residents. The facility census was 105 residents.
1. Record review of Resident #1's MDS showed no MDS had been completed.
2. Record review of Resident #3's MDS showed no MDS had been completed.
3. Record review of Resident #4's MDS showed no MDS had been completed.
4. Record review of Resident #5's MDS showed no MDS had been completed.
5. Record review of Resident #6's MDS showed no MDS had been completed.
6. Record review of Resident #7's MDS showed no MDS had been completed.
7. Record review of Resident #8 MDS showed no MDS had been completed.
8. Record review of Resident #11's MDS showed no MDS had been completed.
9. Record review of Resident #12's MDS showed no MDS had been completed.
During an interview on 12/16/22 at 4:09 P.M., the Regional Support Specialist and Director of Nursing (DON) said:
-MDS's should be completed upon entry, five days after entry and quarterly.
-MDS's should be updated when there are changes in conditions.
-When completing the MDS, the nurse should take into account any past and current behaviors and symptoms.
During an interview on 12/18/22 at 1:52 P.M., pro re nata (PRN as needed) MDS Coordinator said:
-He/she had been helping with MDS's for about 3-4 months up until last week.
-He/she had a full-time job away from the facility.
-The facility did not have a full time MDS Coordinator.
-Someone from the facility would call when there was a new admission and he/she would try to go to the facility after work to complete the entry MDS.
-The facility was behind on MDS's when he/she started helping.
-He/she told the facility that they needed at least one full-time person and a part-time person to get them caught up on their MDS's.
-The facility had MDS's that hadn't been completed from 2017 to present.
MO00210740
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to ensure there were sufficient numbers of nursing staff during five night shifts to ensure resident safety. The facility census was 105 reside...
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Based on interview and record review the facility failed to ensure there were sufficient numbers of nursing staff during five night shifts to ensure resident safety. The facility census was 105 residents.
Record review of the facility's Staffing Policy dated 2001 and revised on October 2017, showed:
-The facility provides sufficient number of staff with the skills and competency necessary to provide care and service for all residents in accordance with resident care plans and the facility assessment.
-Licensed nurses and Certified Nursing Assistants (CNA) are available 24 hours a day to provide direct resident care services.
-Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care.
1. Record review of the Facility Assessment Tool dated 12/2021 through 11/2022, showed:
-The facility was licensed for 120 beds.
-The average number of occupied beds during this assessment was 77.
-The facility had residents all on one floor.
-The facility's Average Daily Facility Staffing Plan showed:
--One Director of Nursing (DON).
--One Assistant Director of Nursing (ADON).
--Two to four Registered Nurses (RN) or Licensed Practical Nurses (LPN) Charge Nurses for each shift.
--Six to nine CNA's per day shift, five to seven CNA's per evening shift, and four to six CNA's per night shift.
--Day shift estimate one staff for every nine residents.
--Evening shift estimate one staff for every 12 residents.
--Night shift estimate one staff for every 15 residents.
-All day estimate one staff for every five residents.
---Note: The facility did not have a current Facility Assessment Tool.
1. Record review of the facility's Daily Nursing Schedule dated 12/17/22, showed the facility census was 110 residents.
Record review of the facility's Daily Punch In and Out for 12/17/22, showed:
-Night shift had two LPN's and one CNA.
--This was one staff member to 36 residents.
---This did not follow the Facility Assessment ratio for night shift of one staff to 15 residents.
---This did not follow the Fire code ratio for night shift of one staff to 20 residents.
Record review of the facility's Daily Nursing Schedule dated 12/23/22, showed the facility census was 115 residents.
Record review of the facility's Daily Punch In and Out for 12/23/22, showed:
-Night shift had one LPN (ADON) and four CNA's.
--This was one staff member to 23 residents.
---This did not follow the Facility Assessment ratio for night shift of one staff to 15 residents.
---This did not follow the Fire code ratio for night shift of one staff to 20 residents.
Record review of the facility's Daily Nursing Schedule dated 12/26/22, showed the facility census was 111 residents.
Record review of the facility's Daily Punch In and Out for 12/26/22, showed:
-Night shift had one RN, one LPN, two CNA's all shift, and one CNA until 5:00 A.M.
--This was one staff member to 22 residents.
---This did not follow the Facility Assessment ratio for night shift of one staff to 15 residents.
---This did not follow the Fire code ratio for night shift of one staff to 20 residents.
Record review of the facility's Daily Nursing Schedule dated 12/27/22, showed the facility census was 111 residents.
Record review of the facility's Daily Punch In and Out for 12/27/22, showed:
-Night shift had one LPN and two CNA's all shift, and one CNA 11:00 P.M. to 6:30 A.M.
--This was one staff member to 27 residents.
---This did not follow the Facility Assessment ratio for night shift of one staff to 15 residents.
---This did not follow the Fire code ratio for night shift of one staff to 20 residents.
Record review of the facility's Daily Nursing Schedule dated 12/31/22, showed the facility census was 109 residents.
Record review of the facility's Daily Punch In and Out for 12/31/22, showed:
-Night shift had one LPN and one CNA.
--This was one staff member to 54 residents.
---This did not follow the Facility Assessment ratio for night shift of one staff to 15 residents.
---This did not follow the Fire code ratio for night shift of one staff to 20 residents.
During an interview on 1/3/23 at 3:01 P.M., the DON said:
-The facility no longer used agency for nursing staff.
-He/she was in charge of staffing.
-When the facility did not have enough staff to work he/she and the ADON would fill in on the night shift.
-He/she worked 12/23/22, 12/24/22, 12/25/22 and 1/2/23 as a floor nurse on the night shift.
-He/she did not punch in or out due to him/her being a salaried employee.
-The ADON did punch in and out when working.
-Only one of them could work the night shift so the other could be the DON or ADON the next day.
-He/she tried to have two nurses and three to four CNAs on the night shift.
-If he/she worked the night shift then he/she did not come to work the next day.
-The ADON took over the DON's duties.
-Sometimes even when he/she or the ADON worked, the facility was still left short staffed and did not meet fire code, as none of the other employees would pick up extra shifts because of being tired.
During an interview on 1/3/23 at 3:01 P.M., the Administrator said this was his/her first day on the job.
MO00211368
Nov 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free of abuse when Resident #2 struck him/her on the side of his/her head out of 14 sampled residents. The census was 104 residents.
On 12/1/22 the Administrator was notified of the past noncompliance which occurred on 10/14/22. The deficiency was corrected on 10/17/22.
Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 4/21 showed:
-Abuse of any kind against residents was strictly prohibited.
-Abuse prevention included recognizing and understanding the definitions and types of abuse that could occur.
-It was understood by the leadership in this facility that preventing abuse required staff education, training and support and a facility-wide culture of compassion and caring.
-Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.
-Physical abuse included, but was not limited to, hitting, slapping, biting, punching or kicking.
-The facility management and staff would institute measures to address the needs of residents and reduce the possibility of abuse and neglect.
1. Record review of Resident #1's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Altered mental status.
-Bipolar disorder, (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
-Paranoid schizophrenia. (a serious mental disorder where people interpret reality abnormally).
-Difficulty in walking.
Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 10/24/22 showed:
-He/she had a Brief Interview for Mental Status (BIMS) score of 14 of 15 indicating he/she was cognitively intact.
-He/she had no history of behaviors.
2. Record review of Resident #2's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Disorder of the brain.
-Vascular dementia, unspecified severity, without behavioral disturbance, (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and nutrients).
-Anoxic brain damage, (injuries caused by complete lack of oxygen to the brain).
-Major depressive disorder (a serious mood disorder that negatively affects how a person thinks, feels and acts).
Record review of the resident's MDS, dated [DATE] showed:
-He/she had a BIMS score of 4 of 15 indicating he/she was severely cognitively impaired.
-He/she had no history of behaviors.
3. Record review of a written statement dated 10/14/22 by the Director of Medical Records showed:
-He/she was in the dining room talking with Resident #1 when Resident #2 walked in.
-He/she spoke with Resident #2 about the day's lunch menu.
-Resident #1 was talking about Resident #2 and Resident #2 overheard it and started walking toward Resident #1.
-He/she escorted Resident #2 to a table to sit.
-Resident #1 kept talking about Resident #2.
-Resident #2 walked toward Resident #1 again, and he/she stood between the two residents, to avoid conflict.
-He/she then pushed Resident #1 in his/her chair out of the dining room, and Resident #2 walked behind him/her and punched Resident #1 on the side of his/her head.
-He/she called a Certified Nursing Assistant (CNA) to take Resident #2 back to his/her room and informed the nurses and manager about the incident.
Record review of a written statement dated 10/14/22 by Resident #1 showed:
-He/she was being taken out of the dining room and Resident #2 came to him/her and hit him/her and knocked his/her glasses off.
-He/she said he/she was not hurt and Resident #2, hit like a girl.
-He/she said the staff separated them, but they didn't have to.
-He/she still gave Resident #2 a cigarette from time to time.
During an interview on 11/14/22 at 2:15 P.M., the Director of Medical Records said:
-He/she was in the dining room and saw Resident #2 coming from the hall at the back entrance of the room.
-He/she spoke to Resident #2 and Resident #1 started to say something to Resident #2.
-Resident #2 walked toward them and he/she got up to redirect him.
-Resident #1 was still talking at Resident #2 harshly, so he/she turned to take Resident #1 out of the dining room.
-Resident #2 came up behind them, reached over his/her shoulder and hit Resident #1 on the side of his/her head, which knocked his/her glasses off.
-It happened really fast.
-He/she told CNA A to take Resident #2 to his/her room, which he/she did.
-He/she had never seen Resident #2 do something like that.
-Resident #1 told him/her they had a disagreement about something and didn't want to let it go that day.
-The two residents had no further issues, and they didn't typically talk or hang out together.
-Neither have a history of behaviors to other residents or staff.
During an interview on 11/14/22 at 2:25 P.M., CNA A said:
-He/she did not witness Resident #2 hit Resident #1.
-The incident happened in the dining room.
-He/she was asked to take Resident #2 to his/her room.
-He/she had never seen the two residents fight each other.
During an interview on 11/15/22 at 9:45 A.M., the Assistant Director of Nursing (ADON) said:
-He/she was present in the building at the time of the conflict between the two residents.
-He/she was not aware of any previous behaviors between the two residents, either before the conflict or currently.
-Both residents were very pleasant.
-He/she would not say the staff had formal training on resident to resident abuse except they were all currently being in-serviced on resident to resident abuse, different types of abuse and resident dignity, which started on 11/14/22.
-The expectation about an incident like this was that the residents would be separated; the witness would get the nurse, who would assess the residents; their care plans should be changed; and physicians and Durable Power of Attorneys (DPOA) should be notified.
-Proper documentation of the incident should be completed.
-The psychiatric physician might be notified if it is suspected the resident might have a change in mental health status.
-Nobody notified him/her of anything.
-He/she thinks the person who was notified might not work at the facility any longer.
Observation on 11/15/22 at 10:10 A.M., showed the resident did not have any visible injury to his/her head.
During an interview on 11/15/22 at 10:10 A.M., Resident #1 said:
-He/she was in a broda chair in the dining room talking to another resident.
-The staff were bringing him/her out of the dining room.
-Resident #2 reached over and hit him/her on the side of his/her head and knocked his/her glasses off.
-He/she did not say anything to Resident #2.
-He/she didn't know why Resident #2 hit him/her.
-He/she was not hurt and his/her glasses were not broken.
During an interview on 11/15/22 at 10:15 A.M., Resident #2 said:
-He/she and Resident #1 were arguing about cigarettes.
-Resident #1 had been speaking rudely to him/her and that was why he/she hit at him/her.
During an interview on 11/15/22 at 12:35 P.M., the Director of Medical Records said:
-He/she had worked at the facility for three months.
-He/she reported the incident to the Business Office Manager, who then reported it to the previous Administrator.
-After the incident between the two residents, he/she talked with Business Office Manager A about what to do, and he/she told him/her, but other than that he/she had had no other training.
During an interview on 11/15/22 at 1:05 P.M., the Administrator said:
-The previous Administrator thought the report made to the state was just for informational purposes, so it was not followed up, nor a formal investigation completed.
-He/she did not know what could have been done differently.
-He/she felt the situation was handled appropriately, since one resident was taken away from the situation, no further conflict happened and there was no injury.
During an interview on 11/16/22 at 3:22 P.M., the previous Administrator said:
-On the day of the incident, Resident #1 felt that Resident #2 was in his/her way and told him/her to move.
-This triggered Resident #2 to hit Resident #1 on the head.
-After the incident, the involved staff and staff at both nursing stations were educated on resident to resident conflicts and reporting the conflicts.
-Education of staff began right after the incident was reported to the State Agency.
-He/she also did training with the facility morning leadership team, which consisted of all department heads. They were to then educate all their staff.
-He/she did not think there was documentation of this training.
-He/she had also been doing monthly education to staff on dealing with people who had mental health issues since he/she became the administrator, including people he/she knew professionally to speak to the staff.
-He/she felt the facility policy on resident to resident abuse was followed.
-The facility plan to prevent further incidents of resident to resident incidents of abuse was to add more staff, and the Administrator was retraining all staff.
MO00208394
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
Investigate Abuse
(Tag F0610)
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 investigate and document an incident of resident to resident alterc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate and document an incident of resident to resident altercation for one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 104 residents.
On 12/1/22 the Administrator was notified of the past noncompliance which occurred on 10/14/22. The deficiency was corrected on 10/17/22.
Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 4/21 showed:
-Abuse of any kind against residents was strictly prohibited.
-Abuse prevention included recognizing and understanding the definitions and types of abuse that could occur.
-It was understood by the leadership in this facility that preventing abuse required staff education, training and support and a facility-wide culture of compassion and caring.
-Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.
-Physical abuse included, but was not limited to, hitting, slapping, biting, punching or kicking.
-The facility management and staff would institute measures to address the needs of residents and reduce the possibility of abuse and neglect.
Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 4/21 showed:
-All allegations were to be thoroughly investigated. The administrator should initiate investigations.
-The individual conducting the investigation should, as a minimum: review documentation and evidence; review the resident's medical record to determine the residents physical and cognitive status at the time of the incident and since the incident; observe the alleged victim, including his/her interactions with staff and other residents; interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident, (as medically appropriate) or the resident's representative; interview the resident's roommate, family members and visitors; interview the resident's attending physician as needed to determine the resident's condition; review all events leading up to the alleged incident; and document the investigation thoroughly and completely.
-Witness statements should be obtained in writing, signed and dated. The witness could write his/her statement or the investigator could obtain a statement.
-If resident abuse, neglect, exploitation, misappropriation or resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.
-The administrator or the individual making the allegation should immediately report his/her suspicion to the following persons or agencies:
--The state licensing/certification agency responsible for surveying/licensing the facility.
--The local/state ombudsman.
--The resident's representative.
--Adult protective services, (where state law provides jurisdiction in long-term care).
--Law enforcement officials.
--The resident's attending physician.
--The facility medical director.
-Immediately was defined as within two hours of an allegation involving abuse or resulting in serious bodily injury; or within 24 hours of an allegation that did not involve abuse or result in serious bodily injury.
-Verbal/written notices were to be submitted via special carrier, fax, e-mail, or by telephone.
-Notices should include, (as appropriate): the resident's name; the resident's room number; the that of abuse alleged; the date and time the alleged incident occurred; the names of all persons involved in the alleged incident; and what immediate action was taken by the facility.
-All possible incidents of abuse, neglect, mistreatment or misappropriation of resident property should be investigated and reported.
-Residents should be protected from any further harm during investigations.
1. Record review of Resident #1's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Altered mental status.
-Bipolar disorder, (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
-Paranoid schizophrenia. (a serious mental disorder where people interpret reality abnormally).
-Difficulty in walking.
Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 10/24/22 showed:
-He/she had a Brief Interview for Mental Status (BIMS) score of 14 of 15 indicating he/she was cognitively intact.
-He/she had no history of behaviors.
2. Record review of Resident #2's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Disorder of the brain.
-Vascular dementia, unspecified severity, without behavioral disturbance, (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and nutrients).
-Anoxic brain damage, (injuries caused by complete lack of oxygen to the brain).
-Major depressive disorder (a serious mood disorder that negatively affects how a person thinks, feels and acts).
Record review of Resident #2's MDS, dated [DATE] showed:
-He/she had a BIMS score of 4 of 15 indicating he/she was severely cognitively impaired.
-He/she had no history of behaviors.
3. Record review of a written statement dated 10/14/22 by the Director of Medical Records showed:
-He/she said he/she was in the dining room talking with Resident #1 when Resident #2 walked in.
-He/she spoke with Resident #2 about the day's lunch menu.
-Resident #1 was talking about Resident #2 and Resident #2 overheard it and started walking toward Resident #1.
-He/she escorted Resident #2 to a table to sit.
-Resident #1 kept talking about Resident #2.
-Resident #2 walked toward Resident #1 again, and he/she stood between the two residents, to avoid conflict.
-He/she then pushed Resident #1 in his/her chair out of the dining room, and Resident #2 walked behind him/her and punched Resident #1 on the side of his/her head.
-He/she called a Certified Nursing Assistant (CNA) to take Resident #2 back to his/her room and informed the nurses and manager about the incident.
Record review of a written statement dated 10/14/22 by Resident #1 showed:
-He/she was being taken out of the dining room and Resident #2 came to him/her and hit him/her and knocked his/her glasses off.
-He/she said he/she was not hurt and Resident #2, hit like a girl.
-He/she said the staff separated them, but they didn't have to.
-He/she still gave Resident #2 a cigarette from time to time.
During an interview on 11/15/22 at 9:45 A.M., the Assistant Director of Nursing (ADON) said:
-The expectation about an incident like this was that the residents would be separated; the witness would get the nurse, who would assess the residents; their care plans should be changed; and physicians and Durable Power of Attorneys (DPOA) should be notified.
-Proper documentation of the incident should be completed.
-The psychiatric physician might be notified if it is suspected the resident might have a change in mental health status.
-Nobody notified him/her of anything.
-He/she thinks the person who was notified might not work at the facility any longer.
During an interview on 11/15/22 at 12:35 P.M., the Director of Medical Records said:
-He/she had worked at the facility for three months.
-He/she reported the incident to the Business Office Manager, who then reported it to the previous Administrator.
During an interview on 11/15/22 at 1:05 P.M., the Administrator said:
-He/she had only been at the facility three weeks, so was not there at the time of the incident.
-The previous Administrator thought the report made to the state was just for informational purposes, so it was not followed up, nor a formal investigation completed.
During an interview on 11/16/22 at 3:22 P.M., the previous Administrator said:
-Neither resident had ever had behaviors at the facility. They had not had any previous problems with the two of them.
-The residents knew each other from their previous facility.
-On the day of the incident, Resident #1 felt that Resident #2 was in his/her way and told him/her to move.
-This triggered Resident #2 to hit Resident #1 on the head.
-After the incident, the involved staff and staff at both nursing stations were educated on resident to resident conflicts and reporting the conflicts.
-Education of staff began right after the incident was reported to the State Agency.
-He/she also did training with the facility morning leadership team, which consisted of all department heads. They were to then educate all their staff.
-He/she did not think there was documentation of this training.
-He/she had also been doing monthly education to staff on dealing with people who had mental health issues since he/she became the Administrator, including people he/she knew professionally to speak to the staff.
Jan 2021
24 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 a resident's Foley catheter (a sterile tube pla...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's Foley catheter (a sterile tube placed in the bladder to drain urine) was in a dignity bag (a covering that can not be seen through that hides the urine of a Foley catheter) while the resident was in a public area and by not ensuring a resident was provided privacy during cares for one sampled resident, (Resident #37) out of 19 sampled residents. The facility census was 62 residents.
Record review of the facility's Dignity policy dated 11/28/12 with a revision date 4/23/18 showed:
-The facility shall promote care for the residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.
-The facility shall consider the resident's life style and personal choices identified through the assessment process to obtain a picture or his or her individual needs and preferences.
-The staff shall carry out activities in a manner which assists the resident to maintain and enhance his or her self esteem and self-worth.
-Protecting and valuing the resident's private space.
-Refraining from practices demeaning to the residents such as leaving urinary catheter bags uncovered.
1. Record review of Resident #37's Face Sheet showed the resident was admitted to the facility on [DATE], and readmitted on [DATE] with the following diagnoses:
-Cerebral Palsy (a group of permanent movement disorders that may appear in early childhood).
-Urinary Tract Infection (an infection in any part of the urinary system).
-Neuromuscular Dysfunction of the Bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition).
Record review of the resident's Care Plan dated 4/27/20, revision date 11/30/20, showed:
-The resident was totally dependent on one staff member to provide a bedbath two times a week.
-The resident was totally dependent on one staff member to provide a bedbath as needed per resident's choice.
-The resident was totally dependent on one staff member for repositioning and turning in bed.
-The resident was totally dependent on one staff member for dressing.
-The resident was totally dependent on two staff members for transferring.
-The resident had a colostomy (a surgical operation in which a piece of the colon was diverted to an artificial opening in the abdominal wall so as to bypass the damaged part of the colon).
-The staff was directed to maintain the resident's dignity during cares.
-The resident had a supra pubic catheter (a tube inserted into your bladder to drain out urine) related to chronic kidney stones.
-The staff was directed to use a privacy bag (dated 5/5/20).
Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 11/30/20 showed:
-The resident had an absence of spoken words.
-The resident was able to make himself/herself understood.
-The resident was able to understand others.
-The resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating he/she was cognitively intact.
-The resident was totally dependent on others.
-The resident needed the assistance of two staff members for all cares.
Record review of the resident's Physician's Order Sheet dated January 2021 showed the staff was directed to:
-Cleanse the Percutaneous Endoscopic Gastrostomy (PEG - a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach) tube site one time a day for Prophylaxis (a course of action to prevent disease).
-Colostomy care every shift for Prophylaxis.
-Suprapubic catheter care one time a day.
Observation on 01/11/21 at 9:51 A.M. showed:
-The resident was observed sitting in a wheelchair in the foyer of the facility, in the front of the receptionist's desk.
-The resident's Foley catheter was not in a dignity bag.
-The urine from the Foley catheter was visible.
-The receptionist was sitting at his/her desk to screen everyone who entered the facility.
-The foyer was the only entrance everyone who came into facility passed through.
-Staff was observed as they passed through the foyer to get from the dining to residents' rooms.
-Management was observed as they passed through the foyer to get to their offices.
During an interview on 1/11/21 at 11:58 A.M., the resident said:
-(The resident used an alphabet board to spell his/her responses).
-This was how the staff usually placed him/her in the foyer.
-There was a dignity bag attached to his/her wheelchair.
-The Foley catheter was not always in the bag.
During an interview on 1/12/21 at 11:20 A.M., Certified Nursing Assistant (CNA) F said:
-He/she has had education during orientation on residents' dignity.
-The resident's Foley should have been in a dignity bag.
During an interview on 1/12/21 at 11:30 A.M., CNA E said:
-They had education during orientation.
-There was a bag the Foley goes into so you do not see the resident's urine.
-The resident should have it in the bag whenever he/she was out of bed.
During an interview on 1/12/21 at 1:15 P.M. RN A said:
-The staff knows to put his/her Foley in a bag.
-They have had education every year on this.
2. Observation on 1/12/21 at 9:45 A.M., showed:
-Certified Nursing Assistants (CNA)'s A, CNA F, and CNA S gave the resident a bed bath while he/she was still in bed.
-The resident's room mate was in the room.
-The curtain between the room mates was not closed allowing the roommate full view of the undressed resident during morning cares.
-(The resident's private areas were exposed).
-The CNA's went in and out of the room to get supplies.
-The curtain around the resident's bed was not closed allowing anyone who walked by the resident's room to see him/her undressed when the door to the hall was opened as the CNAs left the room.
-The curtain to the outside window was not closed.
-The blinds on the window were opened 18 inches allowing anyone who walked by the resident's room on the outside of the facility to see the resident without any clothes on.
-Morning cares took one hour.
3. Observation on 1/12/21 at 10:45 A.M. showed:
-Registered Nurse (RN) A came into the room.
-The Nurse uncovered the resident to work with the resident's feeding tube.
-(The resident's stomach area was exposed).
-(The resident's private area was exposed).
-The RN A told the CNAs to close the curtain between the two residents which they did.
-The curtain to the outside window remained open.
-The blinds on the outside window remained open 18 inches.
-Nursing treatments took 30 minutes.
-(The outside curtain and blinds were left open while morning cares were done for 1.5 hours with the resident undressed, potentially exposing him/her to anyone's view who walked by the window, to the roommate, or people passing by in the hallway).
During an interview on 1/12/21 at 11:20 A.M. CNA F said:
-He/she has had education during orientation on resident dignity.
-He/she knew the curtain between the residents should have been closed.
-He/she had not thought about closing the outside curtain or the blinds.
-The resident's blinds and curtains should have been closed.
During an interview on 1/12/21 at 11:30 A.M. CNA E said:
-He/She had education on providing dignity when doing cares for the resident during orientation.
-He/she knew the drapes between the residents and around the resident should have been completely closed.
-He/she had not thought about anyone being able to see in the window but it could happen.
-The blinds should have been pulled down during morning cares.
During an interview on 1/12/21 at 1:15 P.M. RN A said:
-He/she had seen that the curtain was not closed between the residents which was why he/she had told the CNAs to close it.
-The resident had too many stuffed animals in the window to pull the blind down.
-Anyone would have to bend down to see into the resident's room from outside.
-The blinds and curtain were only opened a few inches.
During an interview on 1/14/21 at 8:30 A.M. CNA D said:
-The staff was taught during orientation to pull the curtains between the residents for privacy.
-The staff was taught during orientation to ensure that no one could see into the residents window from the outside.
-This was to ensure the resident's dignity.
During an interview on 1/15/21 at 8:45 A.M. RN E said:
-The staff has had education on dignity.
-They know to close the curtains when changing a resident.
-They know to put the Foley in a dignity bag.
During an interview on 1/19/21 at 11:15 A.M. the Social Service Assistant (SSA) said:
-Staff training was very poor when he/she started.
-There were no records of competencies that had been completed by the staff.
-The Director of Nursing (DON) was ultimately responsible for training in the facility.
-The DON was no longer working at the facility.
During an interview on 1/19/21 at 2:00 P.M. the Assistant Director of Nursing (ADON) said:
-He/she would expect the staff to close the curtains during cares.
-He/she would have expected that whenever the resident was out of bed the Foley catheter was covered with a dignity bag.
-The staff has had education on dignity.
-The Director of Nursing or Assistant Director of Nursing would have been responsible for staff competencies.
-The Director of Nursing had been auditing those.
-The Director of Nursing was no longer working at the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #101's admission Record showed he/she:
-admitted to the facility on [DATE].
-Was his/her own respon...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #101's admission Record showed he/she:
-admitted to the facility on [DATE].
-Was his/her own responsible party.
Record review of the resident's admission MDS dated [DATE] showed he/she:
-Had severe cognitive impairment.
-Was usually able to make himself/herself understood.
-Was able to understand others.
Record review of the resident's progress notes dated 6/1/20 to 8/7/20 showed:
-No documentation of the incident of the resident's phone going missing and presumed stolen as reported by the facility to the state agency on 6/19/20.
-6/24/20: Social Service Note: The resident's parent indicated that he/she was going to contact the mobile phone company to report the resident's phone as stolen, and that he/she may need a copy of the police report for phone insurance.
-8/4/20: Nursing Note: The resident was discharged from the facility. He/she left the facility by his/her friend's car with all of his/her belongings, including his/her television, phone, and phone charger.
-8/7/20: Nursing Note: The resident's parent was contacted for an address to send the resident's phone and charger to.
-No documentation was present regarding a police report being filed, any facility investigation into the resident's missing property, or the facility's correction of replacing the resident's missing property.
Record review of a document received 1/15/21 at 11:36 A.M. titled, Resident phone misplaced and dated 8/5/20 showed:
-The document was signed by the facility Administrator.
-The resident misplaced his/her phone.
-An extensive search was conducted, including a review of the security camera footage as well as a thorough search of the resident's room.
-The phone could not be located, but there was no evidence indicating the phone was stolen.
-The facility replaced the missing phone.
-The resident discharged home on 8/4/20 and the resident's belongings, including the replacement phone, were provided upon discharge.
-The replacement phone was accidentally left behind by the party who received the resident; the resident's parent was contacted and the replacement phone was mailed to the resident.
-Social Service and Nursing Progress Notes were indicated as information sources for this document.
Record review showed no documentation was present in the resident's record of a facility investigation into the resident's report of missing personal possessions.
During an interview on 1/12/21 at 9:15 A.M., the DON said:
-He/she did recall the incident of the resident's cell phone going missing, although he/she was not DON at that time.
-He/she would look for documentation of a facility internal investigation.
-He/she did recall that the resident's phone never turned up and the facility replaced the phone.
During an interview on 1/13/21 at 11:27 A.M., the Business Office Manager (BOM) said:
-He/She worked at the facility at the time the resident's cell phone was reported missing.
-He/she remembered the resident, but did not recall an incident where he/she needed to request funds from the corporate office to replace missing items for the resident.
-If he/she were requesting money to replace missing cash, funds, or items for residents, he/she must have the facility investigation report to be able to back up the request.
-Social Services staff handled grievances, which could include missing funds/items.
During an interview on 1/14/21 at 10:21 A.M., the Social Services Director (SSD) said:
-He/she could not locate documentation of the facility investigation of the resident's missing/stolen phone, and had requested that documentation from the facility Administrator.
-He/she did not know the resident or the situation, as the resident discharged from the facility before he/she started.
-The process for investigation of incidents was as follows:
--Social Services staff initiate investigations by interviewing the resident(s) involved and other residents and witnesses.
--After the investigation was initiated, if the incident was not a Social Services Department-related issue, the investigation was turned over to the department head that was most closely related to the issue to complete the investigation and provide any correction or other follow-up needed.
--If the issue being investigated involved abuse or neglect, the investigation was completed by the facility Administrator.
--Misappropriation of resident property fell under the area of abuse/neglect.
--He/she did not know if the resident's cell phone was replaced by the facility.
During an interview on 1/14/21 at 1:25 P.M., the facility Administrator said he/she could not find any documentation of an investigation of the resident's missing phone.
During an interview on 1/19/21 at 10:41 A.M., RN A said:
-If a resident reported items missing or stolen, staff was to report that information to the Social Worker and to the DON and they would investigate the allegation.
-All staff were trained to report incidents to the Social Worker and DON, and he/she had no knowledge of anyone in the facility not following that protocol; it was just the normal thing to do.
-He/she had no recollection of an incident of the resident's phone going missing.
During an interview on 1/19/21 at 11:41 A.M., the facility Administrator said:
-Investigations were conducted on a case-by-case basis according to the person and situation.
-For issues that were reportable, the facility would provide the investigation within five working days to the state agency.
-The facility appropriately investigated each situation that should be investigated.
-The investigation process included:
--Collecting statements from anyone with knowledge of the event.
--Reviewing the resident's level of care and any relevant clinical factors.
--Drilling down to determining what the conclusion was for the event.
--Documentation was kept in a soft file which would contain whatever papers were related to the investigation.
-Regarding Resident #101's allegation of misappropriation of property:
--The facility cameras were reviewed and it was not believed to be a likelihood that the resident's phone was stolen; it was more likely that the phone had been lost or misplaced.
--A thorough search of the resident's room was completed and the phone was not found.
-The facility replaced the resident's phone as a corrective action. It was provided to the resident on the date of his/her discharge to ensure it did not get misplaced prior to discharge, but the resident still forgot it when he/she left the facility according to progress notes, and it had to be mailed to the resident.
--According to the facility's Abuse/Neglect/Misappropriation policy, a formal written investigation should have been completed for this incident.
--An interim social worker was leading the investigation into the incident.
--He/she had no other documentation or information related to the incident of the resident's allegation of misappropriation of property.
-Social Work Department staff start investigations.
-He/she was the facility contact responsible for Abuse/Neglect/Misappropriation investigations.
-The facility had no form for conducting formal investigation of incidents.
During an interview on 1/19/21 at 1:59 P.M., the ADON said:
-Allegations of misappropriation of resident property should have a formal investigation completed by the facility.
-Social Services initiated investigation processes.
-He/she believed Social Services was responsible for completing Abuse/Neglect/Misappropriation investigations.
MO00171628
Based on interview and record review, the facility failed to complete a thorough investigation of a Resident to Resident altercation for one sampled resident (Resident #38) who was at risk for potential resident to resident abuse, and failed to thoroughly investigate an allegation of misappropriation of resident property for one closed record resident (Resident #101) out of 19 sampled residents and seven closed record reviews. The facility census was 62 residents.
Record review of the facility's undated Incident/Accident Reports Policy showed:
-Policy: The Incident/Accident Report should be completed for all unexplained bruises or abrasions, all accidents or incidents where there was injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors, or others, and resident-to-resident altercations.
-Procedure:
--An 'incident' was defined as any happening, not consistent with the routine operation of the facility, that did not result in bodily or property damage.
--An 'accident' was defined as any happening, not consistent with the routine operation of the facility that resulted in bodily injury other than abuse.
--An incident/accident report would be completed for:
---All serious accidents or incidents of residents.
---All unusual occurrences.
---Any type of resident abuse.
Record review of the facility's Abuse Prevention and Reporting - Missouri Policy last revised 12/18/10 showed:
-The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
-The facility desired to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This would be accomplished by a comprehensive quality management approach involving the following:
--Concern identification and follow-up: Resident and family concerns would be recorded, reviewed, addressed, and responded to using the facility's grievance procedures. An essential element of customer satisfaction was a timely response back to the family or resident to concerns expressed.
--Internal Reporting Requirements and Identification of Allegations:
---Employees were required to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observed, heard about, or suspected to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator.
---All residents, visitors, volunteers, family members, or others were encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the administrator or an immediate supervisor who must then immediately report it to the administrator.
--Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property would result in an investigation.
---Investigation should be documented, and a copy of the investigation should be kept with the report.
--Supervisors should immediately inform the administrator or person designated to act as administrator in the administrator's absence of all reports of incidents, allegations, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property.
---Upon learning of the report, the administrator or a designee should initiate an incident investigation.
-Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable.
-Final Investigation Report:
--The investigator would report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident.
--The administrator or designee would review the report.
--The administrator or designee was then responsible for submitting a final written report of the results of the investigation and of any corrective action taken to the state agency within five working days of the reported incident.
--The administrator or designee was responsible for informing the resident or their representative of the results of the investigation and of any corrective action taken.
1. Record review of Resident #38's Face Sheet showed, he/she was admitted to the facility on [DATE] with the following diagnoses:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others).
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).
-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
Record review of the resident's Quarterly Minimum Data Set (MDS a federally mandated assessment instrument completed by facility staff for care planning) dated 12/5/20 showed the resident:
-Brief Interview for Mental Status (BIMS) score of 13 out of 15 and was cognitively intact.
-No Behaviors documented.
-Required extensive assistance of one staff for Activity of Daily Living (ADL)
Record review of the resident's 72 hour (hr) Charting Note Progress Notes dated 12/11/2020 at 5:55 A.M. showed:
-Charting was the follow up assessment of a Resident to Resident altercation.
-Resident was alert and oriented. Resident had a sad and worried facial expression.
-No new injuries noted on assessment.
-No skin issues, no bruising noted, or no swelling noted.
Record review of the resident's Behavioral/Mood 12 hour assessment dated [DATE] at 5:55 A.M. showed:
-The resident had no behaviors.
-Location of the incident was the resident room.
-Intervention was staff accompanied the resident outside for a walk.
-Outcome was improved.
-Had no documentation for family or physician notified.
-Had no documentation under behaviors or incident of what happen.
Record review of the resident's Health Status Progress Notes dated 12/11/2020 at 6:15 A.M. showed:
-The resident came out into hallway yelling for the nurse.
-This reporter asked resident what was wrong.
-The resident said it was his/her roommate.
-The roommate came at him/her aggressively, putting his/her hands up saying Come on, come on.
-He/she said that his/her roommate had pushed the resident.
-The resident denied any injury or pain. No injury noted. The resident was removed from room, until his/her roommate was removed from room.
-The resident's roommate was moved to a different room.
-Nursing staff had notified the Assistant Director of Nursing (ADON) of the situation.
Record review of resident's Risk Management portion printed note by the facility administration dated 12/11/20 showed:
-Resident came out into hallway yelling for the nurse.
-This reporter asked resident what was wrong.
-Resident said his/her roommate came at him/her aggressively putting his/her hands up saying Come on, come on.
-Resident said that his/her roommate had pushed him/her.
-Resident said the roommate did that every morning.
-The resident had an assessment completed by facility nursing staff and had no injury noted.
-Resident removed from room while facility staff had talked to the roommate.
-Resident denied any pain or discomfort.
-Additional Documentation: Resident said his/her roommate started yelling at him, put his/her fist up and said come on, come, on. Roommate was moved to a different room. No further incidents noted.
-Resident said that the other resident had pushed him/her.
During an interview on 1/12/21 at 10:33 A.M., the resident said:
-He/she no longer had a roommate.
-He/She had an issue with his/her old roommate, the roommate had come out of the bathroom and became aggressive.
-The roommate was throwing Resident #38's clothes at the him/her.
-The roommate had made a fist and raised it like he/she was going to hit Resident #38.
-The resident said he/she had left the bedroom and yelled for the nurse.
-The roommate was removed from the resident's room and area.
-The old roommate had issues.
-He/she was not hit by the roommate, only threatened.
During an interview on 1/12/21 at 10:39 A.M., the Administrator said:
-He/she was not sure if the facility had contacted State Agency to report the resident to resident altercation.
-The facility has had several other Resident to Resident altercations in past and had been in contact with state related to the incident.
-Most of the Resident to Resident altercations with no injuries were placed in a soft file.
-The facility was looking for the Resident to Resident altercation incident and comprehensive investigation that was to be completed by the facility.
During an interview on 1/13/21 at 9:25 A.M., Certified Nursing Assistant (CNA) A said:
-On 12/11/20 when he/she arrived to work, Resident #38 was seen holding his/her chest and was standing outside his/her room at 6:00 A.M.
-The resident said the roommate had hit him/her and had made threats.
-The roommate was moved out of the resident room to another hallway.
-The roommate had a history of hitting another resident prior to this incident.
Record review on 1/14/21 at 12:00 P.M. of the resident's medical record showed no documentation of a formal or full comprehensive facility investigation report of the resident to resident altercation and none was provided by the facility staff.
During an interview on 1/14/21 at 1:15 P.M., the Nurse Consultant said:
-Falls and other incident investigations were completed in the Point Click Care (PCC) Risk Management portion of the resident's electronic record.
-Since it was part of the facility's Quality Assurance (QA) process, the facility would not provide this information to the surveyors, but they had printed out the summaries of the fall or incidents requested.
During an interview 1/19/21 at 10:00 A.M., RN B said
- Resident to Resident altercations should be documented in the resident's progress notes and staff should complete an incident report and obtain witness statements as needed.
-When a resident had an incident, Nursing staff would assess the resident and notify the resident's physician and family, and follow any physician's orders.
-Then nursing staff would complete the fall or incident investigation in PCC Risk Management portion of the resident's electronic record.
-Nursing staff would complete a follow-up 72 hour assessment in the resident's electronic record.
-Facility administration would be responsible for reviewing and completing the comprehensive investigation and follow-up documentation in the resident's electronic record and Risk Management portion.
During an interview on 1/19/21 at 11:41 A.M., the Administrator said:
-Facility process for conducting an appropriate investigation would be individualized with each person and incident.
-He/She kept a soft file in his/her office of any resident to resident altercation.
-Documentation of resident to resident altercations would be provided if they were a reportable incident.
-Each investigation would include an witness statement, clinical factors and would determine the conclusion, if found.
-Part of the investigation facility staff would had put in place safety measure to keep the resident safe, such as to separate the residents who was involved in incident and/or one-one staffing for resdient safety.
-The facility did not have a formal investigation process at that time.
During an interview on 1/19/21 at 1:59 P.M., the Assistant Director of Nursing (ADON) said:
-The facility staff should have completed a chart audit of the residents' medical records, but due to the turnover of Director of Nursing (DON), the facility had not been monitoring the residents' medical records.
-Related to the facility's process for Resident to Resident altercations would expect:
-Nursing staff should assess the residents involved, including vital signs.
-Staff would ensure the safety of the residents and would then notify the resident's physician, family member and the administrative staff of the incident.
-Nursing staff on duty at the time of the incident would be responsible for documenting in the resident's medical record under risk management related to the resident's incident.
-Documentation should be comprehensive and include who, where and what happen.
-The nursing staff would also obtain any witness statement if possible, at that time.
-Nursing staff were to complete a resident assessment for the residents involved and documentation in the resident's progress notes any findings.
-The DON or administrator would complete the follow-up investigation, along with social services staff.
-Social Services staff would be responsible for follow-up interviews with the residents and staff. They would complete the comprehensive investigation and document the outcome, findings, and root causes, and any steps taken.
-The investigation and follow-up would be reviewed by InterDisciplinary Team (IDT).
-During clinical meeting and staff meetings, they would review any issues and update the resident's care plans at that time.
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**
2. Record review of Resident #37's face sheet showed the resident was admitted on [DATE], and readmitted on [DATE] with the fol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2. Record review of Resident #37's face sheet showed the resident was admitted on [DATE], and readmitted on [DATE] with the following diagnoses:
-Cerebral Palsy (a group of permanent movement disorders that may appear in early childhood).
-Urinary Tract Infection (an infection in any part of the urinary system).
-Major Depression.
-High Blood Pressure.
-Open wound on the left buttock.
-Pressure ulcer on the back stage 3 (ulcers that involve full thickness skin loss).
-Cellulitis of unspecified part of limb (a bacterial skin infection).
-Insomnia (persistent problems falling asleep and staying asleep).
-Neuromuscular Dysfunction of the Bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition).
-The resident did not have a guardian.
Record review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) showed: the following entries:
-4/13/20 Entry tracking record (a MDS record that must be completed every time a resident was admitted or readmitted into a Nursing Home).
-7/15/20 Discharge assessment (a MDS record that must be completed every time a resident leaves the facility - hospital, transfer, or death).
Record review of the Nurses' Progress notes showed:
-The resident went to a nearby hospital for cellulitis in his/her right hip, dated 7/15/20.
-The resident and resident's family was notified.
-There was no documentation that showed the resident or family had been notified in writing of the reason the resident was transferred to the hospital.
-There was no documentation the Physician had been notified that the resident had been transferred to the hospital.
-The resident was back from the hospital, dated 7/21/20.
-There was no documentation the Ombudsman had been notified.
Record review of the resident's MDS showed:
-7/20/20 Entry tracking record.
-8/11/20 Discharge assessment.
Record review of the Nurses' Progress notes showed:
-Hospital update, dated 8/14/20.
-The resident was back from the hospital, dated 8/14/20.
-There was no documentation that showed when he/she had went to the hospital.
-There was no documentation that showed the resident or his/her family had been notified of the resident's transfer to the hospital in writing.
-There was no documentation that showed the Ombudsman had been notified of the resident transfer to the hospital.
Record review of the resident's MDS showed:
-8/14/20 Entry tracking record.
-9/23/20 Discharge assessment.
Record review of the Nurses' Progress notes showed:
-No documentation the resident went to the hospital on 9/23/20.
-There was no documentation that showed when he/she had returned from the hospital.
-There was no documentation that showed the resident or his/her family had been notified of the resident's transfer to the hospital in writing.
-There was no documentation that showed the Physician had been notified the resident had been transferred to the hospital.
-There was no documentation that showed the Ombudsman had been notified of the resident transfer to the hospital.
Record review of the resident's MDS showed:
-10/6/20 Entry tracking record.
-10/19/20 Discharge assessment.
Record review of the Nurses' Progress notes showed:
-There was no documentation that showed when the resident had went to the hospital.
-There was no documentation the resident had returned to the facility on [DATE].
-There was no documentation that showed the resident or his/her family had been notified of the resident's transfer to the hospital in writing.
-There was no documentation the Physician had been notified the resident had been sent to the hospital.
-There was no documentation that showed the Ombudsman had been notified of the resident's transfer to the hospital.
Record review of the resident's MDS showed:
-10/20/20 Entry tracking record
-11/18/20 Discharge assessment.
Record review of the Nurses' Progress notes showed:
-The resident went to a nearby hospital for pain related to his/her suprapubic catheter, dated 11/18/20.
-There was no documentation that showed the resident or his/her family had been notified of the resident's transfer to the hospital in writing.
-There was no documentation the Physician had been notified the resident had been sent to the hospital.
-There was no documentation that showed the Ombudsman had been notified of the resident's transfer to the hospital.
-Readmit, dated 11/25/20.
Record review of the Hospital's Discharge summary showed:
-The resident was admitted on [DATE] for a plural effusion on the left side (a build up of fluid in the tissues that line the lungs and the chest).
-The resident was discharged to the facility on [DATE].
Record review of the resident's MDS showed an Entry assessment dated [DATE].
During an interview on 1/19/21 at 9:30 A.M. the Social Services Director (SSD) said:
-There was no documentation the family was notified the resident was sent to the hospital except on 7/15/20.
-There should have been a transfer form filled out by the resident's nurse before the resident left the facility, they have not been doing it.
-It would be his/her responsibility to notify the Ombudsman for admissions and discharges.
During an interview on 1/19/21 at 11:00 A.M. the Assistant Director of Nursing (ADON) said:
-The resident and family would be notified the resident was going to the hospital and why they were going.
-The nurse who sent the resident to the hospital or the Charge Nurse would be responsible for doing this.
-He/she verified that there was no documentation that the family had been notified the resident was to be sent to the hospital or why they went except on 7/15/20.
-He/she verified there was no documentation that a discharge notice was sent with the resident when he/she went to the hospital.
3. During an interview on 1/15/20 at 8:45 A.M. Registered Nurse (RN) E said:
-All documentation should be done on the electronic chart (E-chart), that was where he/she charted.
-He/she would notify the resident's family why he/she going to the hospital by telephoning them.
-He/she would tell the resident's family which hospital the resident was going to.
-All the above would be documented in the resident's E-chart.
-He/she did not know anything about sending anything to the Ombudsman or who would do that.
-The DON was doing chart audits to see if all the charting that needed to be done was done as it should be.
-The DON was no longer working there.
During an interview on 1/19/21 at 9:30 A.M. the Social Services Director (SSD) said:
-He/she had only been in this position a short time.
-There have been three Directors of Nursing (DON) in the last year.
-The facility was working hard to fix things like this.
-He/she did not know the notification had to be in writing.
-He/she did no know about notifying the Ombudsman, they have not been doing it.
-It would be his/her responsibility to notify the Ombudsman for admissions and discharges.
During an interview on 1/19/21 at 11:00 A.M. the Assistant Director of Nursing (ADON) said:
-The resident and family would be notified the resident was going to the hospital and why they were going.
-The notification should have been in writing, they have not been doing that.
-The nurse who sent the resident to the hospital or the Charge Nurse would be responsible for doing this.
-Currently they were not notifying the Ombudsman when a resident discharged .
-He/She did not know the Ombudsman was supposed to be notified of a discharged resident.
-Social Services would be responsible for notifying the Ombudsman.
During an interview on 1/19/21 at 2:00 P.M., the Social Services Assistant said:
-He/she was not aware a resident was supposed to get a discharge notice with appeal rights upon discharge from the facility.
-He/She was not aware the Ombudsman was supposed to be contacted immediately for any emergency discharges.
-He/She was not aware the Ombudsman was supposed to be notified at least monthly for any other discharges.
-He/She had not been providing resident's a copy of the discharge notice with appeal rights.
During an interview on 1/19/21 at 2:13 P.M., the Assistant Director of Nursing (ADON) said:
-A resident's physician should be contacted if the resident had a change of condition to obtain an order to discharge the resident.
-If it is an emergency discharge, the resident's physician may be contacted after the resident has left the building to update the physician and obtain the order to discharge the resident.
-The facility had not been giving residents who discharged from the facility a discharge notice with the right to appeal notices.
-To his/her knowledge, social services was responsible for notifying the Ombudsman of any discharges from the facility.
MO00180634
Based on interview and record review the facility failed to provide a resident with a discharge notice with the right to appeal upon discharge from the facility, failed to ensure the resident was provided with a discharge plan, failed to allow the resident to return to the facility after his/her improper discharge, failed to notify the resident and family in writing the reason of the transfer to the hospital, and failed to notify the Ombudsman of the resident's discharge from the facility for one closed record resident (Resident #1) and one sampled resident (Resident#37) out of 19 sampled residents and seven closed records. The facility census was 62 residents.
Record review of the facility's undated Discharge/Transfer of Resident policy showed:
-The purpose was to provide safe departure from the facility and to provide for continuity of care and treatment.
-Explain the discharge procedure to the resident and family.
-An attending physician's order was required to discharge.
-Inform all departments of anticipated and actual discharge.
-Have the resident or sponsor sign Personal Inventory of Effects form.
-Document discharge summary.
-NOTE: The policy does not direct staff to provide the resident with a Discharge Notice with appeal rights nor does it direct the facility to notify the Ombudsman of a resident's discharge from the facility.
1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Mood disorder with known physiological condition.
-Psychoactive substance abuse.
-Major Depressive Disorder.
-Suicidal ideation.
-Nontraumatic intracerebral hemorrhage (brain bleed).
Record review of the resident's nursing notes dated 1/7/21 showed:
-The resident hit another resident and spit on the resident while he/she was on the floor.
-Resident #1 was taken to his/her room and staff provided 1:1 observation.
-The other resident said he/she wanted to press charges against the resident and the police were called.
-The police placed the resident under arrest and removed him/her from the building.
-The resident's family and physician were notified of the incident.
Record review of the resident's social service notes dated 1/12/21 showed:
-After conferring with the corporate office it had been decided the resident would not be allowed to return to the facility due to his/her behaviors and safety.
-The resident's guardian and hospital were notified.
-The ombudsman was called and advice received.
-Referrals to other facilities were sent.
Record review of the resident's medical record showed:
-No documentation the resident was given a discharge notice with appeal rights upon the resident's discharge on [DATE].
-The ombudsman was not notified of the resident's discharge from the facility on 1/7/2021 until 1/12/21.
During an interview on 1/15/21 at 12:00 P.M., the Corporate Nurse and the Social Services Director said:
-The resident was not given a discharge notice when he/she left the facility.
-He/She did not notify the ombudsman of the resident's discharge when he/she left the facility.
-The facility did not want the resident to return to the facility due to his/her past behaviors.
-The facility would give the resident a discharge notice that day and would take the resident back if he/she appealed the discharge.
During an interview on 1/19/21 at 8:10 A.M., the Social Services Director said:
-The facility did not give the resident a discharge notice after he/she said the facility would do so on 1/15/21.
-He/She referred the state surveyor to the administrator for further details.
During an interview on 1/19/21 at 10:27 A.M., the Social Services Director said the resident did not get a discharge notice on 1/15/21. Any additional information would have to be obtained from the administrator.
During an interview on 1/19/21 at 11:15 A.M., Registered Nurse (RN) A said:
-Nursing did not give the resident a discharge notice when he/she was discharged from the facility.
-He/She did not know who was responsible to give the discharge notice and thought maybe it might be nursing's responsibility.
-He/She was not working on the day this resident was sent out.
During an interview on 1/19/21 at 11:15 A.M., the Administrator said:
-The resident had a behavior towards another resident.
-The other resident called the police and pressed charges against Resident #1.
-Resident #1 was taken to jail by the police department.
-The resident's parent then took the resident from jail to the hospital.
-The facility's corporate legal department was consulted regarding the incident and told him/her since the resident was taken to jail and his/her parent removed him/her from jail to a hospital, the resident was no longer the facility's responsibility.
-The facility did not give the resident a discharge notice when he/she was removed from the facility to jail.
-The resident was not given an emergency discharge notice.
-The resident was not going to be allowed to return to the facility.
During an interview on 1/19/21 at 2:13 P.M., the Assistant Director of Nursing (ADON) said:
-Resident #1 was not given a discharge notice or a notice with his/her right to appeal his/her discharge from the facility.
-The facility's corporate office was contacted regarding Resident #1 and was told that because the resident required one to one observation due to his/her behaviors, the facility did not have to take the resident back once his/her hospitalization was completed.
-The facility's corporate office said if not allowing the resident to return resulted in citations, they would take the citation because they were not going to allow the resident to return to the facility.
-At the time the resident left the facility with police, it was not known if the resident was going to come back to the facility, so the staff did not do any discharge paperwork.
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** 3. Record review of Resident #37's face sheet showed the resident was admitted on [DATE], and readmitted on [DATE] with the foll...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #37's face sheet showed the resident was admitted on [DATE], and readmitted on [DATE] with the following diagnoses:
-Cerebral Palsy (a group of permanent movement disorders that may appear in early childhood).
-Urinary Tract Infection (an infection in any part of the urinary system).
-Major Depression.
-High Blood Pressure.
-Open wound on the left buttock.
-Pressure ulcer on the back stage 3 (ulcers that involve full thickness skin loss).
-Cellulitis of unspecified part of limb (a bacterial skin infection).
-Insomnia (persistent problems falling asleep and staying asleep).
-Neuromuscular Dysfunction of the Bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition).
Record review of the resident's MDS showed:
-4/13/20 Entry tracking record (a MDS record that must be completed every time a resident was admitted or readmitted into a Nursing Home).
-7/15/20 Discharge assessment (a MDS record that must be completed every time a resident leaves the facility - hospital, transfer, or death).
Record review of the resident's Nurses' Progress notes showed:
-The resident went to a nearby hospital for cellulitis in his/her right hip, dated 7/15/20.
-The resident and resident's family was notified.
-There was no documentation the Physician had been notified that the resident had been transferred to the hospital.
-There was no documentation the resident received a bed hold notice.
Record review of the resident's MDS showed:
-7/20/20 Entry tracking record.
-8/11/20 Discharge assessment.
Record review of the resident's medical record showed there was no documentation the resident received a bed hold notice on 8/11/20.
Record review of the resident's MDS showed:
-8/14/20 Entry tracking record.
-9/23/20 Discharge assessment.
Record review of the resident's medical record showed there was no documentation the resident received a bed hold notice on 9/23/20.
Record review of the resident's MDS showed:
-10/6/20 Entry tracking record.
-10/19/20 Discharge assessment.
Record review of the resident's medical record showed there was no documentation the resident received a bed hold notice on 10/19/20.
Record review of the resident's MDS showed:
-10/20/20 Entry tracking record
-11/18/20 Discharge assessment.
Record review of the resident's medical record showed there was no documentation the resident received a bed hold notice on 11/18/20.
4. During an interview on 1/15/21 at 8:45 A.M. Registered Nurse (RN) E said he/she did not know anything about giving the resident a bed hold policy upon discharge from the facility.
During an interview on 1/15/21 at 12:30 P.M., RN B said:
-He/She has been employed at the facility since September 2020 and he/she was not aware of the bed hold policy and procedure.
-He/She had not seen the bed hold notice, and has sent residents out to the hospital, but has not explained the bed hold policy or had them sign the bed hold form.
-He/She had not been told that he/she had to provide the resident with a bed hold notification at the time the resident was transferred to the hospital.
-He/She would provide a copy of the bed hold notification form to the resident if he/she knew that was supposed to be done prior to sending the resident to the hospital.
During an interview on 1/19/21 at 11:15 A.M., RN A said:
-Nursing does not give the resident a bed hold policy when he/she is discharged from the facility.
-He/She did not know who was responsible to give the bed hold policy.
-He/She was not aware a resident was supposed to get a bed hold policy when he/she was discharged from the facility.
-He/She was not working on the day this resident was sent out.
During an interview on 1/19/21 at 2:00 P.M. the ADON said:
-Upon discharge, the nursing staff usually send copies of the resident's Face Sheet and physician's orders to go to the hospital with the resident.
-He/She was notified that they were supposed to give the resident a bed hold notice whenever a resident is sent to the hospital and they have not been doing that.
-The facility had not been giving residents who discharged from the facility a bed hold policy.
During an interview on 1/19/21 at 2:00 P.M., the Social Services Assistant (SSA) said:
-He/she was not aware a resident was supposed to get a bed hold policy upon discharge from the facility.
-He/She had not been providing resident's a copy of the bed hold policy.
MO00180634
2. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Mood disorder with known physiological condition.
-Psychoactive substance abuse.
-Major Depressive Disorder.
-Suicidal ideation.
-Nontraumatic intracerebral hemorrhage (brain bleed).
Record review of the resident's nursing notes dated 1/7/21 showed:
-The resident hit another resident and spit on the resident while he/she was on the floor.
-Resident #1 was taken to his/her room and staff provided 1:1 observation.
-The other resident said he/she wanted to press charges against the resident and the police were called.
-The police placed the resident under arrest and removed him/her from the building.
-The resident's family and physician were notified of the incident.
Record review of the resident's social service notes dated 1/12/21 showed:
-After conferring with the corporate office it had been decided the resident would not be allowed to return to the facility due to his/her behaviors and safety.
-The resident's guardian and hospital were notified.
-The ombudsman was called and advise received.
-Referrals to other facilities were sent.
Record review of the resident's medical record showed:
-No documentation the resident was given a bed hold policy upon the resident's discharge on [DATE].
During an interview on 1/15/21 at 12:00 P.M., the Corporate Nurse and the Social Services Director (SSD) said:
-The resident was not given a bed hold policy when he/she left the facility.
-The facility did not want the resident to return to the facility due to his/her past behaviors.
-The facility would give the resident a bed hold policy that day and would take the resident back if he/she appealed the discharge.
During an interview on 1/19/21 at 8:10 A.M., the SSD said:
-The facility did not give the resident a bed hold policy after he/she said the facility would do so on 1/15/21.
-He/She referred the state surveyor to the administrator for further details.
During an interview on 1/19/21 at 11:15 A.M., the Administrator said:
-The resident had a behavior towards another resident.
-The other resident called the police and pressed charges against Resident #1.
-Resident #1 was taken to jail by the police department.
-The resident's parent then took the resident from jail to the hospital.
-The facility's corporate legal department was consulted regarding the incident and told him/her since the resident was taken to jail and his/her parent removed him/her from jail to a hospital, the resident was no longer the facility's responsibility.
-The facility did not give the resident a bed hold policy when he/she was removed from the facility to jail.
-The resident was not going to be allowed to return to the facility.
During an interview on 1/19/21 at 2:13 P.M., the ADON said:
-Resident #1 was not given a bed hold policy.
-The facility's corporate office said if not allowing the resident to return resulted in citations, they would take the citation because they were not going to allow the resident to return to the facility.
-At the time the resident left the facility with police, it was not known if the resident was going to come back to the facility, so the staff did not do any discharge paperwork.
Based on observation, interview and record review, the facility failed to ensure the Bed Hold notification was provided to three sampled residents (Resident #42, #1, and # 37) or their responsible party for signature, upon discharge to the hospital out of 19 sampled residents and seven closed records. The facility census was 62 residents.
Record review of the facility's Bed Hold Policy, revised on 9/16/17, showed the purpose was to ensure that the residents and/or resident representative are notified of the facility bed hold policy and conditions for return to facility upon admission and at the time of a transfer from the facility. The guideline showed the facility's bed hold policy applied to all residents. It showed:
-The bed hold policy will be given to the resident and/or resident representative upon admission to the facility, at the time of transfer from the facility and if the bed hold policy under the state plan or the facility's policy were to change.
-In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital.
-The facility will hold a bed for the duration required by each state. After the required bed hold period, or if there is no state required bed hold period, the resident shall receive the next available bed when they are ready to return, even if there is a waiting list, unless certain conditions apply.
-The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital.
Record review of the facility's undated Discharge/Transfer of Resident policy showed:
-The purpose was to provide safe departure from the facility and to provide for continuity of care and treatment.
-Explain the discharge procedure to the resident and family.
-An attending physician's order was required to discharge.
-Inform all departments of anticipated and actual discharge.
-Have the resident or sponsor sign Personal Inventory of Effects form.
-Document discharge summary.
-NOTE: The policy does not direct staff to provide the resident with a bed hold policy notice upon a resident's discharge from the facility.
1. Record review of Resident #42's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including urinary tract infection, pain, diabetes, dementia without behavioral disturbance, high blood pressure, anxiety disorder, obesity, vitamin deficiency, depression and other specified disorders of adult personality and behavior. The Face Sheet showed the resident was his/her own responsible party, but he/she had an emergency contact who was also the resident's power of attorney (a person previously identified to make decisions for an individual in the event of inability to make wishes known).
Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/14/20, showed:
-The resident's Brief Interview for Mental Status (BIMS) was 15 out of 15 showing he/she had no cognitive incapacities.
-The resident had no mood, behaviors or psychosis/delirium.
-The resident needed extensive assistance with transfers and physical assistance with bathing needed, but no assistance noted with dressing grooming eating.
-The resident was always incontinent.
-The resident had no infections during the lookback period.
-The resident was not taking any antibiotics during the lookback period.
Record review of the resident's Nursing Notes showed:
-On 9/14/20 at 8:15 A.M., the resident was outside on a smoking break and told other peers he/she did not feel well. He/She complained of being tired and was speaking slowly with his/her eyes closed. Staff brought the resident in and took the resident's oxygen level and it was at 87 percent (%). Staff rushed the resident to his/her room and placed him/her on oxygen, placed him/her in bed and lifted his/her feet. The resident's blood pressure was 73/35 and the resident was groggy, but able to respond to questions. Staff called for an ambulance and checked his/her oxygen levels again (it was at 89 %) and the resident became increasingly more conversational. Oxygen was decreased when the resident's oxygen level reached 98 %. The ambulance transported the resident to the hospital of the resident's preference.
-The notes did not show that the resident or his/her emergency contact was provided with information regarding the bed hold policy and did not show the resident's physician was notified of the resident's need for hospitalization.
-On 9/16/20 the resident was readmitted to the facility from the hospital. He/She was alert and oriented. His/Her vital signs (temperature, blood pressure, respirations, pulse) were stable and he/she was self-propelling in his/her wheelchair. The resident is an active nicotine user. He/she self-transferred, toileted himself/herself and was incontinent of urine when in bed. The resident received an antibiotic for treatment of a urinary tract infection.
-On 10/11/20 the nurse was called by staff to evaluate the resident out in courtyard where he/she was smoking. Upon arrival, the resident was sweating heavily and pale. He/She was responsive when his/her name was called, but appeared lethargic and was keeping his/her eyes closed. The resident stated he/she was having abdominal pain from constipation. His/Her vital signs were oxygen at 94 % on room air, respirations were 16 and shallow, temperature was 95.2, blood sugar was 245, heart rate was 98, and blood pressure was 80/40. The Assistant Director of Nursing (ADON) notified the resident's physician and received orders to provide fluids for hydration and to obtain a lab for presence of urinary tract infection. The resident was not cooperative and at 11:14 A.M., the ambulance was called to transport the resident to the hospital Emergency Medical Services (EMS-ambulance) were called to transport resident to emergency room (ER).
-The notes did not show the resident or his/her emergency contact was provided with any information or notification regarding the bed hold policy.
-On 10/13/20 the resident returned to the facility from the hospital. He/She was alert and oriented without any distress. His/her diagnosis was urosepsis (a condition that develops from a urinary tract infection that has not been treated). His/He physician, pharmacy and Director of Nursing (DON) was notified of the resident's re-admission and admitting orders.
-On 12/6/20 the resident became unresponsive outside during smoke time, the resident was in his/her wheelchair upon nursing intervention, the resident opened his/her eyes and responded. He/She said he/she was not feeling good. The resident's blood pressure was 74/32 on the first reading, and the second reading was 83/42. The resident's hands were cold from being outside and his/her oxygen level was not registering. Nursing staff sent the resident to the hospital via ambulance. Nursing staff notified the Nurse Practitioner, DON and the resident's responsible party.
-There was no documentation showing the nursing staff provided the resident or his/her emergency contact with information or notification about the bed hold policy.
-On 12/8/20 the resident returned to the facility from hospital and was alert and oriented. He/She denied pain and his/her vital signs were within normal limits.
Record review of the resident's electronic record showed there was no documentation showing the resident (or his/her responsible party) was provided with a notification of the bed hold or had signed a notification of bed hold upon each of his/her hospitalizations.
Observation and interview on 1/11/21 at 10:44 P.M., showed the resident was sitting in his/her wheelchair eating a meat snack. He/She was dressed for the weather and was alert and oriented to person, place and time. He/She said:
-He/She was independent with bathing, dressing, grooming, transferring and toileting.
-He/She currently had a yeast infection (a fungal infection that causes irritation, discharge and itchiness of the vagina).
-He/She had been to the hospital for recurrent urinary tract infections (and has a history of urinary tract infections).
-During his/her hospitalizations the facility did not explain anything to him/her about bed holds upon discharge and he/she did not recall signing any form regarding holding his/her bed while he/she was in the hospital.
-He/She is his/her own responsible party and he/she never received a copy of a bed hold form that his/her emergency contact or family signed for him/her.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #37's face sheet showed the resident was admitted on [DATE], and readmitted on [DATE] with the foll...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #37's face sheet showed the resident was admitted on [DATE], and readmitted on [DATE] with the following diagnoses:
-Cerebral Palsy (a group of permanent movement disorders that may appear in early childhood).
-Urinary Tract Infection (an infection in any part of the urinary system).
-Major Depression.
-High Blood Pressure.
-Open wound on the left buttock.
-Pressure ulcer on the back stage 3 (ulcers that involve full thickness skin loss).
-Cellulitis of unspecified part of limb (a bacterial skin infection).
-Insomnia (persistent problems falling asleep and staying asleep).
-Neuromuscular Dysfunction of the Bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition).
-The resident did not have a guardian.
Record review of the resident's Physician's Order Sheet for April and May 2020 showed:
-The resident had an order to be seen by Psychiatric Services on 4/18/20.
-The resident had an order to be seen by Psychiatric (Services) to treat and evaluate on 5/6/20.
Record review of the resident's MDS showed on 7/15/20 Discharge assessment (a MDS record that must be completed every time a resident leaves the facility - hospital, transfer, or death).
Record review of the resident's POS for July 2020 showed there was no documentation of a physician's order to send the resident to the hospital on 7/15/20.
Record review of the resident's Nurses' Progress notes showed:
-The resident went to a nearby hospital for cellulitis in his/her right hip, dated 7/15/20. The resident and resident's family was notified.
-There was no documentation the resident's physician was notified of the resident's discharge to the hospital.
-The resident was back from the hospital, dated 7/21/20.
Record review of the resident's Psychiatric Services report showed the resident was seen by Psychiatric Services on 8/2/20.
Record review of the resident's MDS showed an 8/11/20 Discharge assessment.
Record review of the resident's POS for August 2020 showed there was no documentation of a physician's order to send the resident to the hospital on 8/11/20.
Record review of the resident's MDS showed an 9/23/20 Discharge assessment.
Record review of the resident's POS for September 2020 showed there was no documentation of a physician's order to send the resident to the hospital on 9/23/20.
Record review of the resident's Nurses' Progress notes showed:
-No documentation the resident went to the hospital on 9/23/20.
-There was no documentation that the resident's family or physician had been notified of the resident's discharge to the hospital.
Record review of the resident's MDS showed an 10/19/20 Discharge assessment.
Record review of the resident's POS for October 2020 showed there was no documentation of a physician's order to send the resident to the hospital on [DATE].
Record review of the resident's Nurses' Progress notes showed:
-No documentation the resident went to the hospital on [DATE].
-There was no documentation the resident's family or physician had been notified of the resident's discharge to the hospital.
Record review of the resident's MDS showed an 11/18/20 Discharge assessment.
Record review of the resident's POS for November 2020 showed there was no documentation of a physician's order to send the resident to the hospital on [DATE].
Record review of the resident's Nurses' Progress notes showed the resident went to a nearby hospital for pain related to his/her suprapubic catheter, dated 11/18/20.
During an interview on 1/15/20 at 8:45 A.M. RN E said:
-If a resident needed to go to the hospital he/she would get an order from the physician.
-He/she would enter the order on the POS.
-He/she would notify the resident's family why he/she going to the hospital.
-He/she would tell the resident's family which hospital the resident was going to.
-All the above would be documented in the resident's chart.
-Not all the nurses chart as well as they should.
-He/she was taught what and where to chart in orientation.
-He/she would tell the Social Service Director (SSD) if a resident needed an appointment and the SSD would make the appointment, usually within the week.
-The DON was doing chart audits to see if all the charting that needed to be done was done as it should be.
-The DON was no longer working there.
During an interview on 1/19/21 at 9:30 A.M. the SSD said:
-The resident should not have had to wait months to see a psychiatrist.
-At the time the resident's physician ordered a psychiatry consultation, the facility was utilizing virtual physician's visits.
-He/she would make an appointment within three days.
-The resident should have been able to see the psychiatrist within a week.
-If the psychiatrist could not come in to the facility, they could do a video evaluation.
-Ensuring the resident had a Physician's appointment was his/her responsibility.
-He/she had only been in this position a short time.
-There have been three DONs in the last year.
-The facility was working hard to fix things like this.
-He/she verified that there was no documentation of any order by the resident's physician to send the resident to the hospital.
-There should have been a physician's order to send the resident to the hospital.
-There should have been documentation which hospital the resident went to and why he/she was sent to the hospital.
-There was no documentation the family was notified the resident was sent to the hospital except on 7/15/20.
-It was the Nurse's responsibility when they take an order to ensure it was documented in the resident's chart.
During an interview on 1/19/21 at 11:00 A.M. the ADON said:
-He/she would expect the staff would get an order from the resident's physician to send a resident to the hospital if he/she needed to go.
-The physician's order would be documented on the resident's medical chart (on the Physician's Order Sheet).
-The physician's order would be followed in a timely manner, not months later.
-At the time the resident's physician ordered a psychiatry consultation, the facility was utilizing virtual physician's visits.
-The resident and family would be notified the resident was going to the hospital and why they were going.
-He/she verified that the resident did not have a physician's order written in the chart stating that the resident was to go to the hospital.
-He/she verified that there was no documentation that the family had been notified the resident was to be sent to the hospital or why they went except on 7/15/20.
-The DON was responsible to ensure the nurses have been educated on physician's orders, and what to do when a resident transfers to a hospital or different facility.
-The facility did not have any documentation of education that had been provided to the staff.
-The DON was no longer working at the facility.
2. Record review of Resident #7's admission face sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Hypertension.
-History of Stroke
-Type II Diabetes Mellitus.
Record review of the resident's hospital Discharge summary dated [DATE] showed:
-The resident's medications were to be continued with no changes include; Lisinopril Tablet 40 milligram (mg) , one tab by mouth daily.
-The medication had no diagnosis listed with the medication, to indicate it's use.
-Listed under the resident's primary diagnosis section showed a diagnosis of Hypertension.
Record review of resident's Nursing Note dated 7/1/20 at 9:04 A.M. showed the resident:
-Had a physician order for Lisinopril Tablet 40 mg.
-Nursing staff was to give one tablet by mouth one time a day for indicate use of Nutritional Supplement.
Record review of Mircomedex drug reference for Lisinopril showed:
-The medication was used for treating high blood pressure.
-Nutritional supplement was not a FDA approved indication for use.
Record review of the resident's Quarterly MDS dated [DATE] showed the resident:
-Had a BIMS score of 12 out of 15 and was cognitively intact.
-Had a diagnosis of hypertension.
Record review of the resident's POS and MAR dated 1/1/21 to 1/31/21 showed:
-The resident had a physician's order dated 6/30/2020 for Lisinopril Tablet 40 mg to be given one tablet by mouth one time a day.
-The indicated use of the medication was listed as Nutritional Supplement.
Record review of the residents Nutrition Progress Note dated 1/8/21 at 11:41 A.M. showed:
-Had no Supplement Intakes ordered.
-His/Her weight stability was desirable at this time.
Observation of medication administration on 1/14/21 at 7:50 A.M., by Certified Medication Technician (CMT) C showed:
-CMT C gave Resident #7 one tab of Lisinopril 40 mg.
-The indicate use listed on the MAR for the medication was for nutritional supplement.
During an interview on 1/15/21 at 8:50 A.M. and at 9:23 A.M., RN B said:
-Lisinopril's indicated use was for hypertension.
-He/she would expect physician's order for Lisinopril be indicated use for hypertension and not as nutritional supplement.
-When he/she would received the new physician order for a medication and he/she would place the new order into Point Click Care (is a electronic medical record systems).
-He/She would then send the new physician's order to the pharmacy, and they would review the order.
-The pharmacy would review the resident's physician order and if they had any questions about the new order, they would call the facility.
-He/She would usually double check or verify the physician's orders against paperwork received.
-He/She was unsure who and when the facility completes a monthly chart audits.
-The medical chart audits were not being completed during the day shift.
During an interview on 1/19/21 at 11:03 A.M., CMT C said:
-When he/she gives medications, he/she looks at the residents physician's order for the medication and the indicated use or diagnosis for that medication.
-In review of physician's order, if he/she had found something that does not make sense, he/she would verify the medication order with charge nurse and the resident's physician if needed.
-Lisinopril would been given for high blood pressure.
During an interview on 1/19/21 at 10:04 A.M. , RN B said:
-The resident's Lisinopril medication was for high blood pressure not as a nutritional supplement.
-The nurse or CMT who would had entered the resident's physician's order for Lisinopril, had entered the wrong indication of use.
-The facility nursing staff and CMT's should ensure they had accurately transcribe physician's orders and to include the proper indicated use or diagnosis on each medication order.
-The facility's CMT or licensed nurse staff are responsible for reviewing the resident's physician order to ensure giving the right medication and for the right indicated use.
-The facility CMT and nursing staff monitor the residents POS and MAR's as needed.
-He/She was not aware who was responsible, or if the facility had auditing system in place for the resident's medical records including physician's order.
During interview on 1/19/21 at 1:59 P.M., ADON said:
-The facility staff should had been completing chart audit of the resident's medical records, but due to the turnover of Director of Nursing (DON), the facility has not been completed monitoring of the resident medical records.
-Nursing management should be monitoring to ensure resident's physician order has been transcribed accurately.
-He/She would expect the facility nursing staff to ensure resident's medication had the proper use or diagnosis for a blood pressure medication.
Based on observation, interview, and record review, the facility staff failed to ensure accurate documentation of the use of a Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle); failed to obtain a physician's order for a continuous blood glucose monitor for one sampled resident (Resident #13); failed to accurately transcribe physician's orders to include the proper use or diagnosis for a blood pressure medication, for one sampled resident (Resident #7); and failed to ensure a resident had an appointment with a psychiatrist in a timely manner and failed to obtain a physician's order when sending a resident to the hospital for one sampled resident (Resident #37) out of 19 sampled residents. The facility census was 62 residents.
Record review of internet reference guide from Mircomedex Drug Reference for Lisinopril (a prescription medication used to treat high blood pressure and heart failure) indication for use showed the Federal Drug Administration (FDA) indicated the medication for the treatment of hypertension (HTN- high blood pressure), acute myocardial infraction (heart attack) and heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood).
1. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Shortness of breath.
-Sleep Apnea (a condition that occurs when the airway becomes narrow as the muscles relax during sleep which reduces oxygen in the blood and causes arousal from sleep).
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).
-Acute and Chronic Respiratory Failure with hypoxia (Respiratory failure is a clinical condition that happens when the respiratory system fails to maintain its main function, which is gas exchange between oxygen and carbon dioxide resulting in low blood oxygen levels).
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
Record review of the resident's care plan dated 4/22/20 and updated on 6/29/20 showed:
-The resident had altered respiratory status and difficulty breathing.
-Interventions included:
--Bilevel Positive Airway Pressure (BiPAP - a method of noninvasive ventilation assisted by a flow of air delivered similar to a CPAP, except BiPAP delivers pressure with inhalation and exhalation. Used to treat sleep apnea), titrated settings 15/3 centimeters of water pressure (cmH2O), on at bedtime and off in the morning.
-The resident had diabetes and required blood glucose monitoring.
Record review of the resident's physician's History and Physical dated 4/23/20 showed:
-The resident had diagnoses that included sleep apnea and receiving CPAP therapy, Obesity hypoventilation syndrome ([NAME] - a condition in some obese people in which poor breathing leads to lower oxygen and higher carbon dioxide levels in the blood), COPD, and diabetes.
-Plan included continuing CPAP therapy for sleep apnea, and monitor accu-checks (blood glucose monitoring) for hypoglycemia (low blood glucose levels).
Record review of the resident's physician's Progress Note dated 5/8/20 showed he/she had diagnoses of sleep apnea with CPAP therapy and diabetes.
Record review of the resident's physician's Progress Notes dated 5/19/20, 7/21/20, 8/10/20, 8/18/20, 9/2/20, and 9/17/20 showed:
-The resident had diagnoses of sleep apnea with CPAP therapy and diabetes.
-The plan included staff monitoring the resident's accuchecks for hypoglycemia.
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/26/20 showed the resident:
-Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15.
-Required extensive staff assistance with bed mobility, transfers, dressing, and bathing.
-Required limited staff assistance with eating and personal hygiene.
-Required insulin seven out of seven days during the look-back period.
-Did not use supplemental oxygen therapy or a CPAP.
Record review of the resident's physician's Progress Note dated 10/29/20, 11/18/20, 12/16/20 showed:
-The resident had diagnoses of sleep apnea with CPAP therapy and diabetes.
-The plan included staff monitoring the resident's accuchecks for hypoglycemia and continue with CPAP therapy.
Record review of the resident's Physician's Order Sheet (POS) dated December 2020 and January 2021 showed:
-Accuchecks before meals and at bedtime.
-CPAP set at 14 cm H20, put on at bedtime and remove in the morning.
--No documentation for an order for a continuous blood glucose monitor.
Record review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated December 2020 and January 2021 showed:
-Staff documented completing accuchecks before meals and before bedtime daily.
-Staff documented the resident wore his/her CPAP every night.
--No documentation the resident wore a continuous blood glucose monitor.
Observation of the resident's room on 1/12/21 at 10:08 A.M., 1/14/21 at 8:25 A.M. showed a CPAP machine on the resident's nightstand and a blood glucose monitor on the resident's bedside table.
During an observation and interview of the resident on 1/15/21 at 10:05 A.M. showed:
-A CPAP machine on his/her nightstand and a blood glucose monitor on his/her bedside table.
-He/She said the CPAP machine was at his/her bedside, but the supplies to use the CPAP were in his/her closet.
-Staff cleaned his/her CPAP a few months ago and put the supplies in his/her closet and it has been there since that time.
-He/She had not worn his/her CPAP in months.
-Observation of a blood glucose monitor attached to the resident's abdomen with a blood glucose reading device on his/her bedside table.
-He/She said he/she had a continuous blood glucose monitor attached to his/her abdomen and kept the blood glucose reading device on his/her bedside table.
During an interview on 1/19/21 at 11:09 A.M., Registered Nurse (RN) A said:
-He/She did not know if the resident wore his/her CPAP or not since it was scheduled to be applied at night and he/she works during the day.
-He/She had never removed the CPAP from the resident in the mornings.
-He/She did not know where the resident's CPAP supplies were stored.
-If staff initialed the resident's MAR/TAR, that would indicate the staff administered the medication or treatment.
-He/She would think if the resident's MAR/TAR for the CPAP was initialed by staff, that would indicate the CPAP was on the resident.
-If the resident did not wear the CPAP, he/she would expect a nurse's note showing that.
-The resident had a continuous blood glucose monitor.
-The blood glucose monitor was applied to the resident's abdomen and he/she kept the reading monitor at his/her bedside.
-Staff would look at the resident's blood glucose reading monitor in his/her room and document the results on the monitor to the resident's MAR/TAR.
-He/She did not know if the resident had a physician's order for the continuous blood glucose monitor.
-He/She supposed the resident should have an order for the continuous blood glucose monitor since it was applied to the resident's abdomen and the facility was using it for the blood glucose results that were documented.
During an interview on 1/19/21 at 2:06 P.M., the Assistant Director of Nursing (ADON) said:
-He/She was not aware the resident was not wearing his/her CPAP machine.
-He/She was not aware the staff were documenting the resident was wearing his/her CPAP machine.
-If staff initial the resident's MAR/TAR, that would indicate that treatment was completed.
-If a treatment was not completed or the resident refused a treatment, he/she would expect staff to write a nursing note.
-The resident should have an order for a continuous blood glucose monitor if he/she was wearing one and staff were utilizing the monitor for documentation of the resident's blood glucose.
-Nursing management should monitor/audit MAR/TARs for accuracy, but it has not been done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
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 complete a written discharge summary and coordinate discharge plann...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a written discharge summary and coordinate discharge planning with the resident's legal guardian for one closed record resident (Resident #107) out of 19 sampled residents, and seven closed record reviews. The facility census was 62 residents.
Record review of the facility's undated Discharge/Transfer of Resident policy showed:
-Purpose: to provide safe departure from the facility, and to provide for continuity of care and treatment.
-Explain the discharge procedure to the resident and family.
-Provide additional health education or medication instruction information for the resident or family as indicated in lay terminology.
-Ongoing resident/family conferences should address health education and potential discharge planning needs.
-Initiate measures for follow-up care as indicated (Social Services, Home Health Care, etc.).
-Document discharge summary. Include notes on specific instructions given (medications, dressings, etc.) to resident and responsible parties in lay terminology.
1. Record review of Resident #107's admission Record showed he/she:
-admitted to the facility on [DATE].
-Had a designated legal guardian.
-discharged home with family on 6/12/20.
-Had diagnoses which included:
--History of Traumatic Brain Injury.
--Major Depressive Disorder.
--Schizoaffective Disorder (a mental condition that causes loss of contact with reality and mood problems), Bipolar Type (includes episodes extremely elevated and excited mood and episodes of depression).
--Anxiety Disorder.
--Mild Cognitive Impairment.
--Hypothyroidism (below normal function of the thyroid gland which regulates metabolism).
Record review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/1/20 showed:
-The resident was cognitively intact.
-Assessment of the resident's mood showed mild clinical symptoms of depression.
-The resident required assistance with Activities of Daily Living (ADLs) as follows:
--Transfer between surfaces: supervision (oversight, encouragement, or cueing) with physical assistance of one staff.
--Walking in room: limited assistance (the resident was highly involved in the activity; staff provided guided maneuvering of limbs or other non-weight-bearing assistance) with physical assistance of one staff.
--Walking in the corridor: limited assistance with physical assistance of one staff.
--Toilet use: supervision with physical assistance of one staff.
--Personal hygiene: limited assistance with physical assistance of one staff.
--Bathing: supervision with physical assistance of one staff.
--Walking and turning around and facing the opposite direction while walking: the resident was not steady and was only able to stabilize with human assistance.
-The resident received antipsychotic, antianxiety, and antidepressant medications every day.
-The resident received opioid medications three out of the last seven days of the lookback period.
-The resident's guardian or legally authorized representative participated in the assessment.
-The resident's guardian or legally authorized representative was the information source for the resident's goal setting related to remaining at the facility or pursuing community living options.
Record review of the resident's Progress Notes dated 5/2/20 showed a Social Service Note: Social Services followed up with guardian with the resident earlier this week and the guardian updated Social Services that he/she was attempting to transfer the resident to another state where the guardian resided. Social Services would start discharge planning and follow up with the email the guardian sent with needed information.
Record review of the resident's care plan dated 5/7/20 showed he/she:
-Had an ADL self-performance deficit related to disease process, schizoaffective disorder, and an arm fracture. Interventions included:
--Supervision by one staff during bathing/showering.
--Supervision by one staff for dressing and undressing.
--Limited assistance by one staff for personal hygiene and oral care.
--Supervision by one staff for toilet use.
--Supervision with transfers.
-Had the potential to be verbally/physically aggressive related to a diagnosis of schizoaffective disorder. Interventions included:
--Administer medications as ordered. Monitor/document for side effects and effectiveness.
--The resident's triggers for aggression were smoking issues, environmental issues, and entertainment issues.
-Was prescribed anti-anxiety, antidepressant, psychotropic (drugs that affect a person's mental state), and opioid medications (a class of highly addictive drugs typically used to control pain).
Record review of the resident's June 2020 Physician's Orders Sheet (POS) showed the resident was prescribed medication for conditions which included:
-Hypothyroidism.
-Schizoaffective disorder.
-Mental disorder.
-Depression.
-Anxiety disorder (controlled medication - medication that is government-regulated due to addictive properties).
-Pain (controlled medication, narcotic medication).
Record review of the resident's Progress Notes dated 6/5/20 - 6/12/20 showed:
-6/5/20: Social Service Note: Social Services had spoken with the resident's guardian multiple times per the resident's request about money, and transferring, and clothing. The guardian was rarely available by phone but mostly responded to email.
-6/9/20: Social Service Note: The resident met with the Social Worker to request to be discharged to his/her significant other's (SO's) home as soon as possible. Outpatient services were identified that could be beneficial for the resident.
-6/11/20: Social Service Note: The resident met with the Social Worker to contact his/her SO to finalize discharge transition. The resident's new local address and telephone number were documented. The resident's choice for pharmacy services was documented, along with address and phone number. Left voicemail for the resident's guardian.
-6/12/20: Nursing Note: New orders noted: okay to discharge home with medications with the exception of narcotics.
Record review of the resident's medical record showed no documentation that a discharge summary was completed.
During an interview on 6/26/20 at 8:25 A.M., the resident's legal guardian said:
-He/she had legal guardianship over the resident.
-The resident had developed a relationship with his/her SO when they both lived at a different nursing facility.
-He/she was fine with the resident discharging from the facility to live with his/her SO, but a better discharge plan should have been completed.
-The resident had a history of mental illness and needed more discharge support.
-The facility did not notify the legal guardian of the discharge.
-The facility only sent two weeks of medication with the resident and did not send controlled medications with the resident. The resident had previously lost his/her identification and had no way to get medications refilled.
During an interview on 1/14/21 at 10:21 A.M., the Social Services Director (SSD) said:
-He/she did not work at the facility during the timeframe of the resident's admission or discharge and did not have personal knowledge of the situation. His/her only source of information was the resident's progress notes.
-There was no discharge summary present in the resident's record or in facility records.
-The resident was discharged from the facility on 6/12/10.
-If a resident had a legal guardian, all discharge planning should be completed in conjunction with the guardian.
-The resident had no legal right to sign anything or make placement decisions independently; that had to be done by the guardian.
During an interview on 1/19/21 at 8:50 A.M., the SSD said that no copy of the resident's legal guardianship paperwork could be located in the resident's medical record or in facility records.
During an interview on 1/19/21 at 11:41 A.M., the facility Administrator said:
-If a resident had a legal guardian, facility admissions staff should ensure that legal guardianship paperwork is obtained and in the resident's record.
-If a resident had a legal guardian who had authority over the resident's medical and care needs, the guardian should be consulted during every step of discharge planning.
During an interview on 1/19/21 at 1:59 P.M., the Assistant Director of Nursing (ADON) said:
-If a resident had a legal guardian who had authority over the resident's medical and care needs, it was expected that the guardian would be involved with all steps of admission, care, and discharge planning.
-The legal guardian's signature should be present on all approval signatures for admission or discharge where signatures were needed.
MO00171853
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident's #6 Facesheet showed he/she was admitted to the facility on [DATE] with following diagnosis:
-Acq...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident's #6 Facesheet showed he/she was admitted to the facility on [DATE] with following diagnosis:
-Acquired absence of left leg below the knee.
-Peripheral vascular disease (PVD - inadequate flow of blood to the extremities).
-Essential hypertension (HTN- high blood pressure).
Record review of the facility's Skin Condition Assessment & Monitoring- Pressure and Non-Pressure, dated 11/28/12 and revised on 6/8/18, showed:
-Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record.
-Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly.
-A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary.
-Residents identified will have a weekly skin assessment by a licensed nurse.
-A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse.
-The licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative of any suspected wound infection.
-The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care.
-A licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes. If observations are acute, physician and responsible party will be notified by charge nurse. Notification will be documented in the resident's clinical record.
Record review of the resident's care plan, 1/18/19 and revised on 1/9/20 showed:
-The resident was at risk for impaired skin integrity related to immobility and prosthetic use.
-His/Her goal was to maintain intact skin through review date.
-Interventions included to document and report to the resident's physician any persistent red areas, and to perform routine skin checks/assessments per protocol.
Record review of the resident's annual MDS, dated [DATE], showed:
-Acquired absence of left leg below the knee.
-Peripheral vascular disease.
-Essential hypertension.
-No wounds present.
-Brief Interview for Mental Status (BIMS) was 15 out of 15 indicating he/she was cognitively intact.
-Independent in Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting).
Record review of the weekly skin assessments showed assessments dated:
-On 6/26/20 the resident's skin was intact with no issues.
-On 6/26/20 the resident's skin was intact with no issues.
-On 7/3/20 the resident's skin was intact with no issues.
-For the month of July 2020 there were no weekly skin assessments charted.
-For the month of August 2020 there were no weekly skin assessments charted.
Record review of the residents POS, dated 1/19/21, showed Weekly Skin Assessment every evening shift every Thursday ordered on 8/6/20.
Record review of the weekly skin assessments showed assessments dated:
-On 9/3/20 the resident's skin was intact with no issues no other skin assessments charted for the month.
-No documentation of a skin assessment due on 10/8/20, 10/15/20, 10/22/20, or 10/29/20.
-No documentation of a skin assessment due on 11/19/20.
-No documentation of a skin assessment due on 12/10/20.
-12/17/20 assessment showed the resident had a scabbed area on left BKA, with some redness tender to touch, tx in progress. No description of scabbed area documented.
-No documentation of a skin assessment due on 12/24/20.
-12/31/20 showed right below knee amputation, wound tx in progress, seen by outside wound care provider. Note: the resident's BKA was on the left leg. No description of the wound were documented by the facility staff.
Record review of the resident's medical record, from June 2020 through January 2021, showed:
-The resident did not have surgical wound assessment documented only the weekly skin assessments referenced above.
Record review of the Physician's Order Sheet, dated January 2021, showed:
-A physician's order for an outside wound care provider to evaluate and treat resident dated 12/9/20. Wound Care orders: left stump cleanse with wound cleanser, apply skin prep (a topical barrier between skin and adhesives) to wound edges then apply santyl [an ointment used for the debridement ((the removal of dead tissue)] to wound bed, cover with border gauze daily and as needed for soilage.
-The order was started on 12/31/20 and started for wound care per the POS.
Record review of the resident's medical record showed no documentation an outside wound care provider had evaluated or treated the resident's wound.
Record review of the resident's annual MDS, dated [DATE], showed:
-Acquired absence of left leg below the knee.
-Peripheral vascular disease.
-Essential hypertension.
-No wounds present.
-BIMS was 15 out of 15 indicating he/she was cognitively intact.
-Required one person physical assistance for ADLs.
Observation on 01/13/21 at 9:45 A.M., showed the resident in his/her room sitting in a wheelchair with no dressing on his/her left BKA wound. The wound was reddish in color with eschar (a dry scab) around the edges of the wound.
Observation on 1/13/21 at 11:16 A.M., of the resident's wound showed:
-The resident's left BKA stump had redness to the right side of the stump with slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) along the top of stump. The slough was approximately 9 centimeters (cm) in length and 1 cm in width.
-A red streak, approximately 8 cm in length, was present from the wound going up the resident's leg.
During an interview on 1/13/21 at 11:18 A.M., RN A said the resident had just seen the outside wound care provider and was going to be discharged to the hospital for surgical abridgement of the stump.
During an interview on 01/13/21 at 11:35 A.M., the resident said:
-The nurses' took care of his/her wound care.
-He/She did not mess with his/her wound or dressings.
-The wound care nurse removed his/her dressings that morning.
3. During an interview on 01/19/21 at 1:17 P.M., RN A said:
-The outside wound care provider's wound documentation was retrievable through the portal, but he/she did not have access to it.
-The only person that had access to the portal was the Director of Nursing (DON).
-He/She could not see what the outside wound care provider had documented or if the wound care provider had seen the resident.
-The resident frequently removed his/her dressing.
-The charge nurse was to monitor the wound after it is seen by outside wound care provider.
-He/She would know a wound had improved by how it looked. The wound would look like it was healing and smaller.
-The nurse that made rounds with outside wound care provider was responsible to put the new orders in the computer.
-The wound nurse was responsible to measure the wound.
-The nurse that performed the wound care nurse responsibilities was unknown at the current time.
-Skin assessments should be done weekly. The weekly skin assessments should be performed by the Charge nurse.
-Skin assessments not charted in computer were not done. They should be charted on the Weekly Skin Observation assessment in the basement part of the computer program.
During an interview on 1/19/21 at 2:00 P.M., the ADON said:
-Nursing staff should be completing skin assessments weekly and they should be monitoring the resident's skin turgor, bruising, what the wound looked like. Wounds are charted on the weekly skin observation assessment unless they are surgical wounds.
-The description should be detailed and paint a picture (of the wound and surrounding skin).
-They should document their weekly assessment on the proper skin assessment form. The documentation should be charted on the weekly skin observations assessment.
-The nurse on duty would do the initial measurements of the wound and is also responsible for completing the weekly skin/wound assessment.
-If a resident was seen by the wound consultant, they will only see a resident with a surgical wound 90 days after the surgery.
-Surgical wounds have a special assessment and are not charted on the skin assessment. They should be documented on the wound assessment form.
-No one had been auditing the skin assessments as they should have been doing because of the turnover in DON.
Based on interview and record review, the facility failed to ensure skin assessments were completed weekly for one sampled resident with a surgical wound, to ensure physician's orders for self-care of a wound was obtained, and to ensure the resident was assessed to perform his/her own wound care for one sampled resident (Resident #58); and failed to adequately document complete and accurate skin assessment findings to include description of wound of one sampled resident (Resident #6) out of 19 sampled residents and seven closed records. The facility census was 62 residents.
Record review of the facility's undated Self Administration of Medication policy showed:
-Residents who request to self-administer drugs would be assessed at the time of admission or thereafter to determine if the practice was safe, based on the results of the self-administration of medications tool.
-The assessment results would be discussed with the attending physician and an order obtained to self-administer if appropriate.
-Bedside storage of prescription or non-prescription medications was permitted when the assessment demonstrated the practice was safe.
-Personnel authorized to administer medications were responsible for documenting the resident's understanding of the use of emergency and routine drugs, signs, symptoms and response to use, and based on observation of resident self-administration.
-Residents who self-administer should be monitored at least semi-annually by licensed nursing personnel.
Record review of the facility's Skin Condition Assessment & Monitoring- Pressure and Non-Pressure, dated 11/28/12 and revised on 6/8/18, showed:
-The purpose was to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented.
-Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly.
-Residents identified will have a weekly skin assessment by a licensed nurse.
-A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse.
-Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the Certified Nursing Assistant (CNA). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment.
-Care givers are responsible for promptly notifying the charge nurse of skin breakdown.
-When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. Physician and responsible party notification will be documented in the clinical record. These changes include, but are not limited to:
--New onset of purulent drainage.
--New onset of odor.
--Cellulitis.
--Increased pain related to wound.
--Significant increase in wound measurements.
-Dressings which are applied to skin tears, wounds, lesions or incisions shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection.
-The licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative of any suspected wound infection.
-The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care.
-Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses note.
-A licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes. If observations are acute, physician and responsible party will be notified by charge nurse. Notification will be documented in the resident's clinical record.
-The attending physician shall be notified within seven (7) to fourteen (14) days of the resident's lack of response to treatment.
Record review of the facility's policy, Physician Orders - Entering and Processing, dated 8/22/17 revision date 1/31/18, showed:
-When receiving a physician's orders by telephone:
-Enter the order into the resident's chart under order tab and according to the instructions for the type of order that was received.
-Be sure to include a diagnosis or indication for use.
-If a diagnosis was not already in the resident's clinical record, ask the physician for a diagnosis.
-Notify the family/responsible party and the resident (if alert).
-Following a physician visit, a licensed nurse will check for any orders that require confirmation.
-The orders will be confirmed by the nurse.
-The instructions for the order will be completed.
-Verbal and Telephone orders will be documented as such in the Electronic Medical Record.
-Physicians will electronically sign verbal and telephone orders.
1. Record review of Resident #58's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), non-pressure ulcer of the skin with necrosis (dead tissue) of the bone, edema (fluid in the tissues), Osteomyolitis (infection of the bone) of the right ankle and foot, staph infection (an infection caused by bacteria on the skin), peripheral vascular disease (PVD - inadequate flow of blood to the extremities), and high blood pressure.
Record review of the resident's hospital record, dated 9/24/20, showed the resident had a right below the knee amputation on 9/21/20, and was discharged to facility on 9/24/20.
Record review of the resident's quarterly MDS, dated [DATE], showed the resident:
-Was alert and oriented with no memory issues.
-Needed extensive assistance with bathing, hygiene, dressing and limited assistance with toileting.
-The resident had no behaviors (to include refusing cares).
-The resident was at risk for developing wounds but it showed the resident had no wounds during the lookback period.
-It did not show the resident received any antibiotics during the look back period.
Record review of the resident's Physician's Order Sheet (POS), dated January 2021, showed physician's orders for:
-Skin inspection/nursing weekly inspection every day shift for monitoring.
-Wound care to the right below knee amputation: cleanse with wound cleanser, apply two non-woven sponges to the incision and apply woven wrap daily (9/25/20).
Record review of the resident's Skin Condition Reports showed:
-9/30/20, showed the resident had a surgical wound that measured 1 centimeter (cm) by 18.24 cm with sutures intact. The edges of the wound were well defined. There was mild swelling with no odor, redness or active bleeding. Wound care was to cleanse the wound with wound cleanser, apply three non-woven sponges to the incision, apply a Kerlix (woven gauze used to cushion and protect wounds) wrap and bandage daily. It showed the resident had pain (unidentified) and pain medication was administered and the resident's care plan was reviewed and updated.
-11/19/20, the resident's surgical wound had 24 sutures that were intact. The resident had no pain, drainage, active bleeding or swelling. The resident had an appointment to have the sutures removed on 11/24/20. The wound treatment was to cleanse the wound with wound cleanser.
-There were no Skin Condition Reports documented after 11/19/20.
Record review of the resident's medical record showed there was no skin condition reports completed between 11/19/20 and 12/9/20 (the resident did not have a skin condition assessment for two weeks).
Record review of the resident's Infection Control Charting showed:
-12/6/20 showed the resident had cellulitis (bacterial infection characterized by inflammation of subcutaneous tissue) and a post-surgical infection at the incision site of his/her right below the knee amputation. There was redness and swelling and the resident received an antibiotic for the infection.
-12/8/20 showed the resident completed the antibiotic for his/her infection to the incision site.
-12/10/20 showed the resident was receiving an antibiotic for cellulitis.
-12/13/20 showed the resident was receiving an antibiotic for symptoms of redness, swelling, and pain at the incision site of his/her right below the knee amputation site. The physician's order was for Keflex (an antibiotic) 500 milligrams (mg) three times daily for symptoms of redness, swelling, and pain (order date 12/8/20).
-12/18/20 showed the redness at the resident's incision line had decreased.
-12/19/20 showed the resident's incision site showed redness, swelling, no increased warmth at site, no foul odor, and minimal drainage. There was significantly less redness at the site (than before). Wound care was provided at this visit. The resident's condition was improving.
-12/20/20 showed redness at the resident's incision site, fluids were offered and received, and the resident's condition was improving.
-12/23/20 showed the resident had and infection to the incision site at his/her right below the knee amputation site. He/She completed the antibiotic (12/23/20) and the resident's condition was now stable.
Record review of the resident's Wound Care Consultant report, dated 12/23/20, showed:
-The wound care consultant completed a complete evaluation of the resident's medical condition to include a physical assessment and medication review.
-The resident was alert and oriented, his/her memory seemed to be intact and he/she appeared to have good judgement and insight but was irritable.
-The wound assessment showed the resident had a surgical wound to his/her right stump that was a full thickness wound and was not healed. The measurements of the wound were 0.5 cm length by 2 cm width by 0.1 cm depth. There was a small amount of drainage noted and the skin around the wound had normal skin moisture and color. There was scar tissue and scabs in the wound.
-The wound orders were to cleanse the wound with wound cleanser, apply a collagen (a material composed of collagen protein that assists with wound healing) pad and cover with gauze. Change the dressing every other day and as needed for soiling.
-They would continue the current plan of care for treating the resident's wound.
-There was no documentation showing the resident had an infection or was receiving antibiotics, there was no documentation showing the resident was completing his/her own wound care, was given instruction on how to perform wound care treatments, or was assessed to complete his/her own wound care treatments.
Record review of the resident's Care Plan, updated 12/31/20, showed the resident had a surgical wound at his/her right below the knee amputation site. The interventions showed staff should:
-Keep incision site clean/dry.
-Monitor site for signs and symptoms of infection (increased drainage, foul odor, redness, warmth).
-Apply treatment as ordered.
-The resident's care plan did not show the resident had infection at the incision site that was treated with antibiotics.
-The resident's care plan did not show that the resident had been assessed to complete his/her own wound care or completed his/her wound care, and it did not show how the nursing staff would monitor the resident's ability to provide his/her own wound care.
Record review of the resident's Physician's Order Sheet (POS), dated January 2021, showed physician's orders for:
-Keflex 500 mg times a day for 10 days for wound (order was dated (1/13/21).
-Lidocaine Gel (a medication used to treat discomfort or pain during certain procedures) 4 percent -apply to right stump topically every 24 hours as needed; apply prior to debridement (the removal of unhealthy tissue from a wound) of his/her right stump (order was dated 12/23/20).
-Wound Care: to open scab area on right stump, cleanse with wound cleanser, apply skin prep (a liquid film-forming dressing that forms a protective barrier to wounds) to the wound edges, apply collagen (used to assist in wound healing) to the wound, cover the wound with gauze, wrap with kerlix every day shift for wound care and every 6 hours as needed for wound care (order was dated 12/23/20).
-An outside wound care provider to evaluate and treat the resident's wound as needed (order was dated 12/9/20).
-Skin inspection nursing weekly assessment on Thursdays, every day shift for monitoring (9/24/20).
-Skin Inspection/ Nursing Weekly Assessment daily on Thursdays.
-There were no physician's orders for the resident to keep medications at bedside or orders stating the resident was able to complete his/her own wound care treatments.
Record review of the resident's Medical Record from 4/21/2020 until January 2021, showed there was no documentation showing the nursing staff assessed the resident's ability to complete his/her own wound care and treatments or how the nursing staff would monitor the resident to ensure the wound care was completed per physician's orders and was adequate. There was no documentation showing the nursing staff educated the resident on completing wound care treatments as the treatments changed or that they observed the resident completing his/her wound care treatments.
Observation and interview on 1/11/21 at 2:23 P.M., showed the resident had a right below the knee amputation that was covered with a brown elastic bandage. The resident was alert and oriented and sat up on his/her bed. He/She said:
-The below the knee amputation occurred during his/her hospitalization in September 2020 and his/her leg was amputated due to a bone infection.
-He/She elected to have the amputation because the infection was not improving.
-He/She was able to transfer himself/herself without assistance but he/she was supposed to be fitted for a prosthetic after his/her wound healed.
-He/She was placed on antibiotics upon re-admission to the facility and has had two rounds of antibiotics due to infection at the incision site.
-He/She was not currently on any antibiotic, but thought he/she should be because there was redness at the site and he/she could easily become septic (severe infection that can create inflammation throughout the body, damaging multiple organs).
-He/She wanted to remain on antibiotics while the wound was healing.
-The wound care consultant started seeing him/her on 12/9/20 and he/she has had two visits so far, but they have only assessed his/her wound.
-The wound care consultant told him/her last week that he/she was going to debride the wound, but he/she would not allow it until after they started him/her on another antibiotic.
-He/She performed his/her own wound care daily because he/she did not trust the nursing staff to do it correctly.
-He/She performed his/her own wound care treatments daily and had all of the supplies to perform treatments in his/her room.
-The resident removed the brown bandage from his/her stump and observation of the site showed a linear incision wound that was partially healed. There were scabs of different sizes across the incision. There was a little redness at the site, but it was without drainage and did not have any odor.
-He/She said he/she was supposed to have a follow up at appointment at the hospital next week.
During an interview on 1/13/21 at 10:20 A.M., the ADON said:
-They have wound care consultants addressing the resident's wound and wound care.
-The wound care consultant started seeing the resident on 12/9/20 and see him/her weekly to measure, assess the resident's wound and provide any follow up treatments.
-He/She has had two visits from the wound care consultants and would be seeing them today.
During an interview on 1/13/21 at 11:02 A.M., RN B said:
-The resident had a surgical wound from his/her amputation.
-He/She developed an infection in the wound and was ordered antibiotics upon re-admission to the facility.
-The physician extended the order, but when the resident completed the antibiotics, the physician did not extend it again.
-The resident had been asking for antibiotics to be prescribed again.
-Initially when the resident was readmitted , his/her surgical wound was red and swollen (a sign and symptom of infection), but since he/she completed the antibiotics, the surgical wound is no longer infected.
-He/She had seen the resident's surgical wound and it does not look to be infected (not swollen, red, with drainage or odor). He/She said he/she had assessed the resident's skin at the wound site and the area had always been a little red but no other signs/symptoms of infection.
-He/She did not observe the resident's wound daily or weekly, but the wound care consultant has started and he/she has completed weekly rounds with them to look at his/her surgical wound (as of 12/23/20).
-They have orders for wound care treatment daily for the resident, but sometimes the resident does not want them to complete the treatment (sometimes the resident would allow them to complete the treatment and sometimes he/she would not allow them to complete the treatment).
-Sometimes the resident does his/her own wound care treatment because the supplies are in his/her room.
-Sometimes the nurses will come in to do the resident's wound treatment and the resident will tell them that he/she had already completed the treatment himself/herself. They would then document treatment as completed on the TAR.
-The resident's wound treatment was to cleanse with wound cleanser, apply skin prep and cover with border gauze.
-They document that the wound care was completed on the resident's medication administration record (MAR)/treatment administration record (TAR).
-He/She did not know if they documented when the resident completed his/her own wound care.
-He/She did not know if the resident had been assessed for his/her ability to complete his/her own wound care, but he/she had observed the resident complete his/her own wound care and the resident was able to complete it.
-He/She did not know whether the resident had a physician's order to complete his/her own wound care.
-They were to complete weekly skin assessments on everyone and the skin assessments were documented on the skin assessment form in the resident's electronic record.
-He/She saw the resident's wound on Monday and did not see anything that would indicate an infection.
-The resident received wound care consultants visits weekly, and he/she did rounds with the consultant last week and the resident refused to be seen because he/she was going to see his/her outside physician this week.
-The resident had an outside physician that assessed his/her wound but they have not received any documentation from the outside physician regarding the resident's wound care.
-The wound care consultant was in the facility and would see the resident today.
Observation and interview on 1/15/21 at 11:29 A.M., showed the resident was in bed resting but was awake. He/She said:
-He/She he was seen by wound care consultants and they assessed his/her wound. The wound consultant did not change the treatment and they did not say that his/her wound was infected, but his/her physician provided a script for more antibiotic.
-He/She completed his/her own treatment to his/her wound yesterday but had not completed the treatment today because he/she had not felt like getting up to do it yet.
-He/She pulled up his/her pant leg and there was no dressing on the surgical wound. The wound looked to have black scabs in several areas and less red, without odor or drainage.
-Observations in the resident's closet showed a box with 4 x 4 gauze, bandage rolls (some were opened and loose and some were in the original packaging), and a box with Santyl (an enzyme that breaks down collagen in damaged tissue and helps healthy tissue to grow) on the packaging (the ointment was not in the box). There was a container of wound cleanser on a small dresser in front of his/her bed.
-The resident said that he/she usually used the wound cleanser to clean the wound then put Santyl on the wound before wrapping it with the gauze.
-While in the hospital, after his/her amputation, the physician (in the hospital) showed him/her how to do his/her own wound care.
-The nursing staff here at the facility do not complete his/her wound care and he/she does not trust them to do it.
-The nursing staff at the facility did not train him/her on how to do his/her wound care and they have not assessed his/her ability to do his/her own wound care.
During an interview on 1/15/21 at 11:48 A.M., RN B said:
-He/She had completed the resident's wound care on occasion and he/she has seen the resident complete his/her own wound care and the resident seemed able to complete his/her own wound care. They do not document watching the resident do their treatment.
-He/She did not know if they documented an assessment showing the resident's ability and capacity for completing his/her wound care according to the physician's orders.
-He/She was not aware if there was a physician's order for the resident to complete his/her own wound care.
-If the resident's wound care was completed they document that it was completed on the resident's Treatment Administration Record by initialing that wound care was completed. They do not document who completed the wound care.
During an interview on 1/19/21 at 2:00 P.M., the ADON said:
-The resident would occasionally allow the wound consultant to treat his/her wound, he/she had refused treatments.
-He/She had completed the resident's wound care before but the resident will also complete his/her own wound care.
-He/She was aware that the resident had been completing his/her own wound care and thought he/she was capable of completing it.
-Wound care should be completed daily according to the physician's orders.
-The nursing staff should be completing weekly skin assessments to monitor the residents wound and overall skin.
-There was no documentation showing the resident was assessed to do his/her own wound care or educated to complete his/her own wound care (follow the physician's orders for wound care.
-There should be an assessment showing he/she can do his/her own wound care/follow physician's wound care orders.
-There should be a physician's order showing the resident can complete his/her own wound care.
During an interview on 2/3/21 at 2:25 P.M., the resident's physician said:
-He/She would have expected staff to educate the resident on how to do his/her own wound care.
-He/She would ha
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** 2. Record review of Resident #103's admission Record showed he/she:
-admitted to the facility on [DATE] with diagnoses which inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #103's admission Record showed he/she:
-admitted to the facility on [DATE] with diagnoses which included:
--Type 2 Diabetes Mellitus with Hypoglycemia (low blood sugar).
--High Blood Pressure.
--Acute Pain.
--Other Symptoms and Signs Involving Cognitive Functions and Awareness.
--Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without Behavioral Disturbance.
--Schizophrenia (a serious mental disorder in which people interpret reality abnormally, often leading to decreased independence in daily functioning).
Record review of the resident's care plan revised 1/9/20 showed he/she:
-Was at risk for falls related to conditions, debility, and weakness.
-Interventions included:
--Nursing staff were to document any fall event and report any fall event to the physician.
--The resident was ambulatory without device; nursing staff were to observe and provide cues and prompts regarding safety and gait.
Record review of the resident's fall assessment dated [DATE] showed he/she:
-Was at risk for falls.
-Had intermittent confusion.
-Had balance problems while standing and walking.
-Was jerking or unstable when making turns.
-Required the use of assistive devices (i.e. cane, wheelchair, walker, furniture).
Record review of the resident's Annual Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/9/20 showed he/she:
-Walked in his/her room independently with staff setup support required.
-Walked in the corridor independently with no staff support required.
-Required supervision (oversight, encouragement, or cueing) for locomotion on unit with one person physical assistance.
-Required supervision (oversight, encouragement, or cueing) for locomotion off unit with one person physical assistance.
-Had no functional limitation in range of motion in upper extremities or lower extremities.
-Did not require the use of any mobility devices.
-Had had no falls in the previous three months.
-Had moderate cognitive impairment.
Record review of the resident's assessments and tracking forms showed the resident:
-discharged from the facility with return anticipated on 11/23/20.
-Was discharged to an acute hospital.
Record review of the resident's progress notes dated 11/23/20 showed:
-Nursing Note: Discharge Summary: The resident was sent to the hospital emergency room by ambulance after a witnessed fall.
-The resident was ambulating in the hallway without assistance and fell.
-The resident hit his/her head on the ground and experienced neurological changes.
Record review of the resident's fall assessment dated [DATE] showed he/she:
-Was at risk for falls.
-Had intermittent confusion.
-Had balance problems while standing and walking.
-Had decreased muscular coordination.
-Was not jerking or unstable when making turns.
-Did not require the use of assistive devices (i.e. cane, wheelchair, walker, furniture).
Record review of documentation titled Fall Note dated 11/23/20 showed:
-The information was received as a typed document, not as a form or formal documentation.
-The resident was observed shuffling, walking down the hallway.
-The resident appeared to lose footing and fell on his/her back and hit his/her head. The fall was witnessed by a Certified Nursing Assistant (CNA).
-The resident was unable to give a description of the event.
-Vital signs were assessed and documented.
-A neurological check was completed as follows:
--PERRLA (pupils equal, round, reactive to light and accommodation) 3 millimeters, both eyes.
--Grips weak.
--No dorsal flexion in feet (backward bending of the foot; occurs when drawing toes back toward the shins).
-The ambulance was called and the resident left on the ambulance on a stretcher to the hospital.
-Notifications were made to the DON, the physician, and to next of kin.
Record review of the resident's medical record showed no documentation a complete and thorough investigation was completed, including interviewing staff and/or witness, the root cause, or interventions after the resident's fall on 11/23/20.
During an interview on 1/15/21 at 9:00 A.M., CNA A said:
-He/She did not witness this resident's fall.
-All nursing staff in the facility were trained on how to respond to falls.
-CNAs wrote a statement if they witnessed a fall, were told by a resident that he/she fell, or found a resident who had fallen. The statement was given to the charge nurse, who entered it into the system.
During an interview on 1/15/21 at 9:10 A.M., RN B said:
-Resident #103 had mobility issues and weakness the day he/she was sent to the hospital, which was how staff noticed something was wrong.
-The resident was assessed following a fall, the physician was notified, and he/she was sent to the hospital for evaluation.
-The resident usually walked okay by himself.
-It was out of the resident's norm to be so unsteady.
-He/she was not the charge nurse who sent the resident to the hospital, but had knowledge of the event.
-He/she believed that the ADON at the time was the nurse who had handled the situation and completed the necessary paperwork.
-The expectation for steps to take following a witnessed fall were as follows:
--Assess whether the resident hit their head, what the resident was doing when the fall happened, how the resident fell, and complete a physical assessment of the resident.
--Neurological checks should be completed if a resident hit their head, it was unknown if the resident hit their head, or if a fall was unwitnessed.
--If there was an injury, the physician was to be called and his/her orders followed (send to hospital for evaluation, order mobile x-ray, etc.).
--If a serious injury was apparent, such as excessive bleeding, 911 should be called immediately.
-Nursing staff were expected to begin the fall investigation in the risk management section of the facility's electronic health records (EHR) system.
-After any fall, the fall investigation should be completed and present in the EHR system.
-The fall investigation was not printed or saved anywhere besides the EHR risk management section that he/she was aware of.
-If a nurse did not know the protocol for the fall investigation, such as agency nurses or new nurses, they should ask another nurse for instructions, as charge nurses knew to start a fall investigation.
During an interview on 1/19/21 at 10:41 A.M., RN A said:
-Fall investigations should be completed after any fall.
-As part of the investigation, the resident and any witnesses needed to be interviewed by the charge nurse.
-That information was entered into the facility's EHR system in the risk management section.
-The team should work to ensure the resident did not fall again; they looked for the root cause of the fall.
-Sometimes it took a few investigations to try to figure out the root cause, especially for residents who could not communicate what happened. Nursing staff had to use their best judgement in those cases.
During an interview on 1/19/21 at 1:59 P.M., the ADON said:
-The protocol following a fall included:
--Assessing the resident.
--Obtaining vital signs.
--If the resident was not responsive, call 911 and administer emergency procedures if needed and appropriate for the resident.
--If appropriate, assist the resident back to a normal, safe position.
--Notify the physician and follow any new orders.
--Notify the Director or Nursing (DON), ADON, and the resident's emergency contact, etc.
--Document the fall under the risk management section in the facility's EHR system.
--The next working day, the interdisciplinary team (IDT) would meet to establish the root cause of the fall and then go from there (i.e. work to resolve medication issues; re-educate the resident and/or staff, etc.).
-- Any new physician or medication orders would be put into place.
-The risk management section of the facility's EHR was under the quality assurance section and was accessible to all nurses.
-Risk management fall documentation was to be comprehensive, including the resident's vital signs, how staff found the resident, etc.
--There were sections to enter the nurse's account of the fall and to include the resident's statement.
--Any additional information about the fall that needed to be placed in the system could be entered.
--Neurological checks were to be completed and documented if the fall was unwitnessed.
-The fall investigation would help determine if extra supports were needed by the resident, such as extra monitoring.
-There was no fall investigation form outside of the risk management EHR system for documenting fall investigations.
-The fall investigation should not just be a paragraph, it should give full detail. Anyone should be able to review the investigation and know what happened.
-The nurse who assessed the resident following the fall should initiate the fall investigation. That would typically be the charge nurse on duty on that unit, but not always.
-It was the responsibility of the DON to complete fall investigations.
-The information provided for the resident was all that could be found; there was no additional investigation information to add.
--The information provided for the resident was not a comprehensive investigation.3. Record review of Resident #46's face sheet showed he/she was admitted on [DATE], readmitted on [DATE] with the following diagnoses:
-Major depressive disorder.
-Hearing loss.
-Absence of left leg below the knee.
-The resident was not his/her own responsible party.
Record review of the resident's Care Plan dated 2/20/19 revision date 12/9/20 showed:
-The resident was a smoker.
-The resident would not smoke in the facility.
-The resident would not smoke without supervision.
-The resident would keep smoking material in a secured location.
Record review of the resident's admission MDS dated [DATE] showed:
-The resident's BIMS was 13 out of 15 indicating the resident was cognitively intact.
-The resident used a wheelchair to move around.
-The smoking area was not checked.
Record review of the residents Smoking Safety Risk assessment dated [DATE] showed:
-The resident was a current smoker.
-The resident required supervision only with smoking.
-No assistance was needed.
-The resident was not able to store smoking material.
During an interview on 1/11/21 at 8:45 A.M. the Activities Director said:
-There were signs on the wall for smoke times: 8:30 A.M., 10:30 A.M., 1:30 P.M., 3:30 P.M., 6:30 P.M., and 8:30 P.M.
-The residents were not to smoke at any other times.
-Because of COVID (a new disease caused by a novel (new) coronavirus) they only let five residents go outside on the smoking patio to smoke at one time.
-The residents had to practice social distancing (stay six feet apart from each other).
-The residents had to be monitored.
-He/she monitored the residents most of the time.
-A Certified Nursing Assistant (CNA) would do it if he/she was not working.
-The residents could not keep their smoking materials (cigarettes or lighters) in their rooms.
-He/she usually went to the store to buy the cigarettes for the residents for the month.
-The families would sometimes bring the residents a carton of cigarettes.
-He/she did not know of any problems regarding the residents smoking in their rooms.
Observation of the resident's room on 1/11/21 at 10:45 A.M. showed:
-The resident had a pack of cigarettes at bedside on the bedside tray table.
-The cigarettes were within reach of the resident.
-There were cigarettes in the pack.
-There was no smell of smoke in the resident's room.
-There was no matches or lighter visible in the resident's room.
During an interview on 1/11/21 at 10:50 A.M. the resident said:
-He/she was a smoker.
-He/she was not supposed to keep cigarettes at bedside.
-The resident said he/she did not feel well enough to go out to smoke that day.
-The resident would not say why he/she had a pack of cigarettes in his/her room.
-The resident would not say if he/she had a lighter or matches in his/her room.
-The resident would not say if he/she smoked in his/her room.
-The nurses kept his/her cigarettes for him/her.
Observation on 1/12/21 at 12:46 P.M. showed:
-The same pack of cigarettes still on the bedside table within reach of the resident.
-The same amount of cigarettes were in the pack.
Observation on 1/13/21 at 10:00 A.M. showed:
-The same pack of cigarettes still on the bedside table within reach of the resident.
-The same amount of cigarettes were in the pack.
During an interview on 1/15/21 at 8:45 A.M. Registered Nurse (RN) E said:
-He/she worked every Friday, Saturday, and Sunday.
-He/she has worked in the facility for the last six months as a nurse.
-He/she coil smell some of the residents smoking in their rooms an average of every other weekend.
-He/she reports it to management.
-The residents could not keep cigarettes or lighters in their rooms.
-He/she had taken cigarettes and lighters away from residents who had been smoking in their rooms.
-He/she had locked the residents cigarettes and lighters in the nurses' cart.
-In the last six months he/she has caught two or three residents smoking in their rooms.
During an interview on 1/19/21 at 11:40 A.M. the Administrator said:
-If a resident was smoking in his/her room they would be counseled.
-If staff find a resident who was smoking in their room he/she would expect staff to report it to him/her.
-The residents should follow the smoking policy.
During an interview on 1/19/21 at 2:00 P.M., the ADON said:
-There have been issues with some of the residents smoking when they are not on smoke break.
-Smoke break times are posted on the wall.
-The staff keeps smoking materials locked up in a cart.
-Smoking assessments should be done quarterly.
-If staff find a resident smoking in their room they should ask them to give up their smoking materials.
-He/she would expect the staff to report anyone smoking in their rooms, or anything else against policy right away to management.
MO00178543
Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent accidents not ensuring a resident did not have smoking materials in his/her room for one sampled resident (Residents #46), failed to thoroughly document falls and complete a comprehensive fall investigation (which described/documented the resident's fall, interventions that were in place prior to the fall, immediate response to the fall, post fall interventions, notification of the resident's physician and responsible party, and analysis of the possible cause of the resident's fall) for one sampled resident (Residents #59) and one closed record resident (Resident #103) out of 19 sampled residents, and seven closed record reviews. The facility census was 62 residents.
Record review of the facility's Fall Prevention Program policy revised 11/21/17 showed:
-A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition, and after any fall incident.
-Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions.
-The Director of Nursing (DON) or Designee was responsible for monitoring the Fall Prevention Program.
Record review of the facility's undated Incident/Accident Reports policy showed:
-The Incident/Accident Report was completed for all unexplained bruises or abrasions, [and] all accidents or incidents where there was injury or the potential to result in injury.
-An 'accident' was defined as any happening not consistent with the routine operation of the facility that results in bodily injury, other than abuse.
-An incident/accident report will be completed for:
--All serious accidents or incidents of residents.
--All injuries of staff, families, and visitors.
--All unusual occurrences.
--All situations requiring the emergency services of a hospital, the police, fire department, or coroner.
--All unexpected events that occur that cause actual or potential harm to a resident or employee.
--Any condition resulting from an accident requiring first aid, physician visit, or transfer to another health care facility.
-An incident/accident report was to be completed by a Registered Nurse (RN) or Licensed Practical Nurse (LPN), and was to include:
--Date and time of an incident/accident.
--Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties.
-An RN or LPN must notify the following if an actual injury occurs:
--Physician.
--Legal representative or interested family member within 24 hours.
-Documentation in Nurses' Notes was to include:
--A description of the occurrence, the extent of injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified.
--A minimum of 72 hours (longer, if indicated) of documentation by all three shifts on resident status after the incident. Vital signs, mental and physical state, follow-up, tests, procedures, and findings were to be documented.
-All incident/accident reports were reviewed, signed, and investigated by the Administrator and the DON or Assistant Director of Nursing (ADON).
Record review of the facility's policy Smoking Safety, dated 11/28/12 revision date 1/22/19 showed:
-The facility would designate areas approved for smoking by residents.
-The designated area would be outside in accordance with state/local standards.
-A smoking Safety Assessment would be completed to determine the level of assistance and supervision needed during smoking.
-Individuals who were non-compliant, potentially dangerous, exercised poor judgment, and showed a lack of concern for the welfares of others would be counseled accordingly.
-Smoking privileges would be revoked if there was a pattern of persistent, hazardous behavior.
-All persons interested in retaining smoking privileges must follow the guideline set forth in the policy.
-The following behavior would jeopardize revocation of the persons' independent privileges: Smoking in any non-designated area, such as resident rooms, bathrooms, hallways, elevators, stairways or a smoke-free courtyard.
-The facility had the right to enforce a policy prohibiting residents from keeping any smoking material in her/her possession for health, safety and security reasons.
-Residents would be instructed, educated and counseled about their inappropriate behavior.
-Documentation would be entered in the (medical) record accordingly.
-Further incidents of non-compliance may result in the loss of independent privileges which means smoking materials would be turned over to a designated staff member, held in a secure location and the resident would only be allowed to smoke when supervised by a responsible individual at the the discretion of the organization.
-Behavior determined to be potentially harmful may jeopardize the person's ability to remain in the health care facility.
-The facility may exercise its right to involuntarily discharge such individuals.
-The facility recognized the potential harm that may result from careless, hazardous smoking and had implemented this policy to maintain a safe living environment.
-Violation of this policy would be taken seriously and appropriate action would be forthcoming.
1. Record review of Resident #59's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including stroke with paralysis (Complete or partial loss of muscle function) of the left and right side, Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), seizures, high blood pressure, psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning), dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses), muscle spasms, and kidney disease.
Record review of the resident's Care Plan dated 10/9/20, showed the resident was at risk for injury due to falls related to debility, weakness and confusion. Goals showed the resident would have oversight, support and preventive measures to insure his/her personal safety through review and the resident would not sustain significant injury through next review date. Interventions showed:
-The resident had an actual fall with no injury related to a broken chair and being left unattended in his/her chair.
-For no apparent acute injury, determine and address causative factors of the fall.
-Physical Therapy evaluation and a new wheelchair was ordered.
Record review of the resident's Nursing Notes showed:
-On 12/1/20 the nurse documented the resident suffered a non-injury fall at 2:30 P.M., and when the nurse arrived in the resident's room, the resident was on the floor next to his/her wheelchair with his/her feet still resting on the wheelchair leg rest. The arm on the wheelchair was also on the floor next to him/her. The nurse documented he/she initiated neurological checks (neurological checkpoints to monitor: level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs-blood pressure, temperature, pulse, respirations and oxygen level) were initiated and vital signs, and both were within normal limits. The resident denied having any pain, and completed range of motion in all extremities without pain. The resident appeared to have no injuries at the time. Nursing staff used a mechanical full body lift to place the resident into his/her bed and he/she was resting comfortably. The nurse notified the resident's family and physician of the resident's fall.
-On 12/2/20 the nurse documented the resident continued on fall follow up, denied any pain, and was currently eating dinner in bed where he/she was fed and supervised. He/She had no changes in his/her level of care and his/her vital signs were within normal limits. The resident was resting comfortably in bed with his/her eyes closed. It showed the resident's wheelchair was still broken.
-There were no further post-fall updates documented in the resident's nursing notes or medical record. There was also no documentation showing any update regarding the resident's wheelchair repair or issue of another wheelchair.
Record review of the resident's Neurological Checks dated 12/1/20 to 12/3/20, showed the nursing staff completed checks on the resident after his/her fall and there were no issues noted.
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/14/20, showed the resident:
-Was alert with significant cognitive incapacities.
-Had no mood or behavior issues, and had no delirium or psychosis.
-Was totally dependent on staff for bathing, dressing, toileting, hygiene, eating transferring and the resident did not walk.
-Used a wheelchair for mobility.
-Had physical limited range of motion on both sides of his/her upper and lower extremities.
-Had two or more falls with injury, without injury and major falls since admission or the last assessment.
Record review of the resident's undated Fall Investigation Report showed an undated report summary, showing:
-When the nurse arrived to the room, the resident was on the floor next to his/her wheelchair and was positioned on his/her left side with his/her feet laying on the foot rest of his/her wheelchair and had his/her eyes closed.
-The physician ordered a physical therapy evaluation for the resident's wheelchair.
-Physical Therapy found the wheelchair to be broken and that it was likely the resident slid out of his/her wheelchair.
-The arm on the resident's wheelchair was off and found on the ground next to him/her.
-A new wheelchair was being ordered for the resident
-The document did not show the date and time the resident fall occurred, what interventions were in place prior to the resident's fall and at the time of the residents fall, when the resident was last seen prior to the observation of the resident on the floor and what the resident was doing when last seen (where was the resident), whether the nurse assessed the resident for injury, whether there was or was not any injury to the resident, when the resident's physician and responsible party was notified of the resident's fall and what the response of the physician was, what the immediate interventions were and what long-term interventions were implemented to prevent future falls.
Observation on 1/13/21 at 9:31 A.M., showed the resident was in bed. The resident's bed was low to the ground, with no mats on the floor. His/Her call light was within reach. The resident was resting comfortably with his/her eyes closed and was wearing soft boots. The resident's wheelchair was beside the resident's bed and the right arm of the wheelchair was off. The wheelchair was not in use.
During an interview on 1/13/21 at 9:33 A.M., Certified Nursing Assistant (CNA) A said:
-He/She was on duty on the day the resident was found on the floor.
-The resident's last fall occurred while he/she was in his/her old wheelchair.
-The resident was sitting in his/her wheelchair and when he/she passed by the resident's room initially, he/she was watching television and his/her wheelchair was tilted back.
-When he/she passed by the resident's room again, he/she saw the resident on the floor.
-The resident was laying on his/her side so he/she called for assistance and the nurse came in and completed an assessment.
-The resident did not complain of pain and had no injuries.
-They were able to get the resident up and into his/her bed.
-This is when they found that the arm of the resident's wheelchair had broken.
-The rehabilitation team assessed the resident's wheelchair and because the resident will lean to the side in his/her wheelchair, they determined that the resident tipped it over and that's how he/she ended up on the floor.
-They determined that the pressure of the resident's weight on the arm of the wheelchair was the problem, but when they called it in to be repaired, they found that it was unrepairable.
-The rehabilitation team got the resident a temporary wheelchair that he/she was using while waiting for the new wheelchair to arrive.
-The resident's current wheelchair had no footrests that would fit and that were proper for his/her positioning.
During an interview on 1/13/21 at 10:07 A.M., Physical Therapist A said:
-The resident was not able to transfer or ambulate without assistance from staff.
-They were still working with the resident on strengthening and mobility.
-They have been working on getting the resident footrests to go on his/her current wheelchair and getting a new wheelchair for the resident because his/her former wheelchair was broken. They have ordered a new wheelchair for the resident.
-They were informed by the nurses that on the day the resident was found on the floor (on 12/1/20) beside his/her wheelchair, the resident fell out of his/her wheelchair after the armrest broke.
-The resident usually leaned forward in his/her wheelchair which was why they had him/her in a tilt back wheelchair, but he/she apparently had also leaned to the side of his/her wheelchair.
-He/She was placed in a tilt back wheelchair for his/her safety.
During an interview on 1/15/21 at 12:30 P.M., Registered Nurse (RN) B said:
-When a resident falls they assess the resident and notify the physician and family, follow any physician's orders and then they would implement any new fall interventions.
-The nurse was responsible for completing the fall investigation in the Risk Management section of the electronic record.
-The Risk Management is part of the facility quality assurance, so they do not print that information out, but they were able to access it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident receiving dialysis (the process of r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident receiving dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein) had a valid physician's order indicating where and when the resident was to go for dialysis treatment and obtain orders directing staff to monitor the resident's dialysis central venous catheter (CVC - a flexible, long, plastic, Y-shaped tube that is threaded through your skin into a central vein in your neck, chest or groin - a connection between a vein and artery to provide access for dialysis treatment) for one sampled resident (Resident #34) out of 19 sampled residents. The facility census was 62 residents.
Record review of the Dialysis Monitoring and Observation policy dated 11/28/12 revised 2/13/18 showed:
-If the resident had a catheter for dialysis, the nurse will assess the catheter site for any signs of drainage and condition of the dressing to the site every shift.
-Document vital signs (blood pressure and pulse at a minimum) following dialysis treatment.
-Document assessment of dialysis catheter site for any signs of drainage and condition of the dressing to the site every shift.
1. Record review of Resident #34's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of:
-End Stage Renal Disease (ESRD - renal failure (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes).
-Dependence on Renal (Kidney) dialysis.
Record review of the resident's Quarterly Review Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/28/20 showed:
-His/Her Brief Interview for Mental Status (BIMS) was 15 out of 15 indicating he/she was cognitively intact.
-He/She received dialysis.
Observation on 1/13/21 at 9:43 A.M. of the resident showed he/she had a dialysis CVC in the residents right chest.
Record review of the resident's Physician Orders dated 1/19/21 showed:
-No physician's orders to send the resident out for dialysis.
-No documentation where to send the resident for dialysis treatment.
-No documentation what days the resident was to receive dialysis.
-No orders to assess the resident's dialysis CVC for bleeding, or signs and symptoms of infection.
Record review of the resident's Care Plan showed:
-No documentation the resident received dialysis treatments, or how often he/she received dialysis treatments.
-No documentation of they type of dialysis access the resident had, or guidance to monitor the dialysis access site for bleeding or signs of infection.
Record review on 1/13/21 at 8:56 A.M. of the resident's electronic health record showed:
-No documentation by facility staff of monitoring resident's dialysis access upon return from dialysis.
During an interview on 1/14/21 at 10:03 A.M., Registered Nurse (RN) A said:
-He/she would expect a doctor's order to send the resident for dialysis.
-He/she would check the orders to see if order was in, and if not would get the order and put it in the system.
-He/she assessed the site for bleeding before and after dialysis.
-Documented on the Treatment Administration Record (TAR).
During an interview on 1/15/21 at 8:59 A.M., the resident said:
-No one monitors his/her dialysis CVC when he/she returned from dialysis.
-He/she went to dialysis three times a week.
During an interview on 1/15/21 at 9:54 A.M., RN E said:
-The care plan should be updated to accurately reflect the resident's condition.
-He/she would expect there to be orders in the chart to send the resident to dialysis.
-Orders included where to send the resident and on what days the resident went to dialysis.
-He/she monitors the dialysis site for bleeding when the resident returns and documented this on the TAR.
-Staff should monitor the resident's dialysis site every shift for bleeding and infection.
-Staff would document the dialysis site was monitored on the resident's Treatment Administration Record (TAR) each shift.
-He/She was unable to locate on the resident's TAR where he/she had documented the assessments of the resident's dialysis access site.
-He/She could not locate on the resident's TAR where staff could have documented the assessment of the resident's dialysis access site since he/she had been admitted to the facility.
During an interview on 1/19/21 at 10:39 A.M., the MDS coordinator said:
-A resident's MDS should accurately reflect the resident's condition.
-If the resident received dialysis treatment, dialysis should be checked on the MDS and documented with the relevant diagnosis.
-The care plan should reflect the resident received dialysis.
During an interview on 1/19/21 at 2:11 P.M. , the Assistant Director of Nursing (ADON) said:
-He/She would expect a resident to have a physician's order to go to dialysis.
-The physician's order should include when and where the resident received dialysis treatment.
-He/She would expect a resident to have an order to monitor his/her dialysis access.
-He/She would expect staff would assess the resident's dialysis access every shift and document it on the resident's TAR.
-Monitoring should be for signs of bleeding or infections.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from unnecessary psychotropic medication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from unnecessary psychotropic medications for one sampled resident (Resident #13) out of 19 sampled residents. The facility census was 62 residents.
Record review of the Pharmacist Medication Review policy dated 11/28/17 showed the Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once per calendar month for each resident residing in certified areas of skilled long term care facility.
-The consultant Pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist. Federally mandated standards of care as well as other applicable standards serve as the basis for review to ensure that a resident's medications are promoting or maintaining the resident's highest level of function in congruence with the resident's therapeutic goals and to identify clinically significant risks and/or adverse medication reactions.
-The review of the medication regimen will include all medications currently ordered, including medications that are ordered as needed. The review will incorporate information from the resident's chart concerning the resident's condition, monitoring side effects, potential for drug interactions, psychotropic medication review, including considerations for dose reduction/optimal dosing, review of the medication administration records and ancillary documentation such as the physician's progress notes, nursing notes and laboratory test results.
-The Consultant Pharmacist will report any irregularities in writing to the attending physician, the Medical Director and the Director of Nursing for follow up. The written documentation will include minimally, the resident's name, the relevant drug and the identified irregularity.
-The Director of Nursing or designee will notify the attending physician of recommendations either in person, by telephone, fax, or other secure system of notification within three business days of receiving the report from the Consulting Pharmacist. If no response is received from the attending physician within three business days following notification, the Director of Nursing will make a second attempt to notify the physician. If the attending physician does not respond after a second attempt, the Medical Director will be notified of the recommendation. The Director of Nursing will notify the attending physician of irregularities that require urgent action the same business day that notification was communicated. If unable to notify the attending physician, The Medical Director will be notified.
-In addition to the written communication intended for the attending physician, the Medical Director and the Director of Nursing, medication regimen review documentation of completed consultation will be maintained in the resident's clinical record. The documentation should include whether or not any apparent irregularities were found, the pharmacist's signature and title and date the review was performed.
-The facility is responsible for ensuring all clinical records are available for review.
-The Consultant Pharmacist is available to consult with the prescribing physicians, Medical Director or nursing staff regarding recommendations resulting from the medication regimen review. It is the responsibility of the facility to ensure that each of the recommendations result in a response by either a physician or nurse as appropriate. The attending physician/Medical Director or designee should document in the medical record that the identified irregularity has been reviewed subsequent action taken, if required. In the event where no change will be made as a result of the identified irregularity, the physician/Medical Director or designee should document rationale in the medical record.
-The documentation of completed medication regimen review should be kept as part of the resident's record to reflect at least twelve months of review.
1. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses:
-Anxiety disorder.
-Major depressive disorder.
-Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems), bipolar type (mood disorders characterized usually by alternating episodes of depression and mania).
Record review of the resident's care plan dated 6/26/20 showed:
-Was prescribed antidepressant, antianxiety, and psychotropic medications.
-Consult with pharmacy and the resident's physician to attempt a dose reduction when clinically appropriate at least quarterly.
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/26/20 showed the resident:
-Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15.
-Required extensive staff assistance with bed mobility, transfers, and bathing.
-Required limited staff assistance with personal hygiene.
-Did not have behaviors.
-Was administered an antipsychotic medication seven out of seven days.
-Was administered an antianxiety medication seven out of seven days.
-Was administered an antidepressant medication seven out of seven days.
Record review of the resident's December 2020 Physician's Order Sheet (POS) showed:
-A physician's order for an outside wound care provider to evaluate and treat as needed dated 12/9/20.
-Buspirone HCl Tablet 5 milligram (mg), give 1 tablet by mouth at bedtime for anxiety dated 5/5/20.
-Hydroxyzine HCl Solution 25 milligram per milliliter (mg/ml), give 25 mg by mouth three times a day for Anxiety and/or Itching dated 5/17/20.
-Bupropion HCl ER (XL) Tablet Extended Release 24 Hour 150 mg, give 1 tablet by mouth one time a day for depression dated 5/6/20.
-Aripiprazole (Ability) Tablet 15 mg, give 1 tablet by mouth one time a day related to Major Depressive Disorder, dated 5/6/2020.
Record review of the resident's electronic medical record showed:
-No documentation of a monthly medication review by the facility pharmacist for 4/20, 5/20, 6/20, 7/20, 8/20, 9/20, and 10/20.
Record review of the resident's pharmacy note in his/her electronic medical record dated 11/18/20 showed Medication Record Review (MRR) review, please see pharmacy recommendations.
Record review of the resident's medical record showed no documentation of the pharmacist recommendation dated 11/18/20 or if the recommendation had been addressed by the resident's physician.
Record review of the resident's pharmacy note in his/her electronic medical record dated 12/21/20 showed Medication Record Review (MRR) review, please see pharmacy recommendations.
Record review of the resident's medical record showed no documentation of the pharmacist recommendation dated 12/21/20 or if the recommendation had been addressed by the resident's physician.
During an interview on 1/15/21 at 10:05 A.M., Registered Nurse (RN) F said:
-When the pharmacist makes a recommendation, he/she gives it to the MDS person or the Assistant Director of Nursing (ADON) for review and follow-up.
-He/She did not have access to the pharmacist's monthly review to know what recommendations were made, if any, or if the recommendations were addressed by the resident's physician.
During an interview on 1/15/21 at 11:38 A.M., the Social Service Director (SSD) said:
-The facility changed pharmacy's in October 2020.
-The old pharmacy would send the monthly pharmacy review and any recommendations to the DON.
-The current pharmacy sent recommendations to the previous DON and the facility could not access those records at that time.
-The facility was not able to provide documentation the pharmacy reviews were addressed by the resident's physician.
-He/She was not able to access the monthly pharmacy reviews that were sent to the previous DON.
-The facility was attempting to contact the previous DON and the previous pharmacy for those records.
Record review on 1/15/21 of the pharmacy monthly medication record review showed:
-On 12/21/20 the pharmacist recommended a gradual dose reduction of the resident's Abilify 15 mg daily. This had not been addressed as of 1/15/21.
--Note: the resident's Buspirone HCl Tablet 5 mg, Hydroxyzine HCl Solution 25 milligram per milliliter (mg/ml) 25 mg, and Bupropion HCl ER (XL) Tablet Extended Release 24 Hour 150 mg had not been addressed for pharmacy recommendations for a gradual dose reduction.
During an interview on 1/19/21 at 11:10 A.M., RN A said:
-Pharmacy recommendations would go to the DON for review and follow-up.
-He/She had no idea if the pharmacy reviews were followed or addressed with the resident's physician.
-He/She did not have access to see what the pharmacist's recommendations were.
During an interview on 1/19/21 at 2:07 P.M., the ADON said:
-Pharmacy recommendations were sent to the previous DON.
-The DON was responsible to ensure the monthly medication reviews were completed and any recommendations were followed up.
-The facility did not have an auditing system to ensure that was completed.
-If the pharmacist made a recommendation, staff should contact the resident's physician for approval.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #27's admission Face Sheet showed the resident was admitted to the facility on [DATE] had diagnosis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #27's admission Face Sheet showed the resident was admitted to the facility on [DATE] had diagnosis including:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-History of cancer of the cervix.
-Was on hospice services (end of life or chronic health palliative care services)
Record review of the resident's significant change MDS dated [DATE] showed the resident:
-BIMS of 5 out of 15 and was severely cognitive impaired.
-While at the facility was placed on Hospice services.
-Was able to make his/her own needs known and able to understand others.
-Required extensive assistant of one staff for Activity of Daily Living (ADL).
Record review of the resident's Hospice Collaboration Log binder showed:
-Had two documented Hospice visit in November on 11-19-20 and 11-25-20.
-No other documentation found for hospice service visits in the resident's Hospice binder before 11/19/20 or after 11/25/20.
Record review of the resident's Quarterly MDS dated [DATE] showed the resident:
-Had a BIMS score of 5 and was severely cognitive impaired.
-Was able to make his/her own need known and able to understand others.
-Required extensive assistant of one staff for Activity of Daily Living (ADL)
-No documentation related to resident on hospice services.
Record review of the resident's Hospice Care Plan reviewed 12/9/20 showed:
-The resident had signed and valid Do Not Resuscitate (DNR) and if the resident stop breathing, display no pulse as a result of failure of the heart to contract effectively or at all.
-The resident was on hospice services for a terminal condition related to a diagnosis of senile degeneration of the brain.
-The hospice aide was to visit per scheduled days.
-Hospice provides RN support per scheduled days.
-The facility was to maintain good communication with hospice staff.
Review of the resident's Point Click Care (PCC) medical records showed the resident had no faxed or scanned hospice documentation related to the resident's completed hospice care visit.
Record review of the resident's progress notes from 11/1/20 to 1/14/21 showed:
-No documentation was found in the resident's progress notes, relate to when hospice staff was on site to provide hospice care services for the resident.
-No documentation was found for ongoing collaboration and communication between the facility staff and hospice staff during the resident's Hospice care visit.
Record review of the resident's Physician Order Sheet (POS) dated 1/1/21 to 1/31/21 showed had a physician's order for the resident to receive hospice services.
During an interview on 1/13/21 at 11:20 A.M., Certified Nursing Assistant (CNA) B said the resident was on hospice services and the hospice was making visits to see the resident.
During an interview on 1/14/21 at 10:05 A.M., RN A said:
-RN A said the resident was no longer on hospice services he/she was not sure the date of discharge from hospice.
-He/She said the business office could verify the resident discharge date .
During an interview on 1/14/21 at 10:10 A.M., the Business Office Manager(BOM) said:
-The resident remained on hospice services according to PCC.
-If the resident had been discharge for hospice services, then he/she would had received a dis-enrollment letter .
-The resident was initial admitted to hospice on 5/11/20.
-He/She going to call the hospice agency to verify and obtain copies of the hospice visit.
During an interview 1/14/21 at 10:35 A.M., the BOM said:
-The resident was on hospice services and he/she had requested copy of the resident's hospice notes from 11/2020 to 1/14/21.
-The hospice staff had reported the resident's last hospice visit was on 1/4/21.
Record review of faxed copy of resident's Hospice Visit Notes showed:
-The facility had received faxed copy of the hospice notes on 1/14/21 at 10:47 A.M.
-They had received copy of hospice visit notes from November 2020 to January 2021.
-The resident's hospice notes from November 2020 - January 2021 was not in the resident's medical record prior to the hospice provider faxing them to the facility.
During an interview on 1/19/21 at 9:50 A.M., RN B said:
-The hospice staff communicate verbally with the facility nursing staff of any resident's treatment changes and change in condition of the resident.
-Hospice staff should document the visit in the resident's hospice binder chart.
-He/She was not aware of who be responsible to ensure hospice staff had completed documentation after a hospice visit.
-The nursing staff would only document in resident's record if they had been informed by hospice staff of any new concerns for the resident, a change of condition or if new orders were received by hospice staff.
-He/She was not aware of the facility policy for monitoring resident's medical record and how or who would be responsible for ensuring to obtain ongoing documentation of resident's outside community care services, including hospice.
During interview on 1/19/21 at 1:59 P.M., ADON said:
-The facility staff should had been completing chart audit of the resident's medical records, but due to the turnover of DON, the facility has not been completed monitoring of the resident medical records.
-Nursing management should be monitoring to ensure resident's have documentation of hospice services notes.
-He/she would expect hospice staff to document their visit in the resident's hospice binder and facility medical records would scan any hospice visit progress notes into the resident's medical record.
-Front line staff do not review the documentation received from an outside service provider until they had been scanned into the resident medical record.
-He/She would expect to see ongoing facility nursing staff notes for resident's hospice visit that would include, something like seen by hospice at the facility today and any findings of the visit that had been communicated by hospice care staff.
Based on interview and record review, the facility failed to maintain medical records for a resident's outside wound care provider, failed to maintain documentation related to a resident's monthly pharmacist medication review, for one sampled resident (Resident #13); failed to maintain documentation of the resident's physician visits for two sampled residents (Resident #13 and #42), and failed to maintain pertinent documentation of the the delivery of hospice care services for one sampled resident (Resident #27) out 19 sampled resident. The facility census was 62 residents.
Review of the facility Hospice Services Policy and Procedure revision on 11/17/17 showed:
-Hospice services staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available for all interdisciplinary staff to access.
-Facility licensed personnel will be responsible to notify hospice service coordinator in event of change of resident condition and prior to transfer to another facility.
-All treatment and services are documented in accordance with the facility's medical record policies and nursing procedures.
Review of the facility's undated Medical Records Policy and Procedure showed:
-The facility was to ensure that a complete accurate and legal record the resident care maintained. The resident's medical record is readily accessible systematically organized to provide a medium, of communication among health care professional involved in the resident care and to facilitate retrieval and compilation of information.
-Record will be audited as needed to assure compliance. Reports of audits will be provided to the Director of Nursing (DON) and to other disciplines as applicable.
-Physician,nursing staff and other health involved in the resident's care will be responsible for making prompt appropriate entries into the resident's record and authenticating them with date, signature and title.
-Respite care records follow the standard facility policy, procedures and forms she be used for all admissions. transfer and discharge.
-DON and medical records personal shall assure that the medical records are maintained in accordance with the facility policies and procedures, and applicable federal and state regulations.
-Nursing documentation are in the nurse's records of the provision of and response to nursing care will be made on the nurses notes record and other specialized nursing forms as appropriate by a licensed and unlicensed nursing personnel.
-Monthly nursing progress notes will be written by licensed nursing personnel.
1. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses:
-Sepsis (infection) due to Methicillin Susceptible Staphylococcus Aureus (a bacteria).
-Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Peripheral vascular disease (inadequate blood flow to the extremities).
-Non-pressure chronic ulcer (open wound) of the lower leg.
-Anxiety disorder.
-Major depressive disorder.
-schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems), bipolar type (mood disorders characterized usually by alternating episodes of depression and mania).
Record review of the resident's care plan dated 6/26/20 showed:
-No documentation the resident had skin impairment.
-Was prescribed antidepressant, antianxiety, and psychotropic medications.
-Consult with pharmacy and the resident's physician to attempt a dose reduction when clinically appropriate at least quarterly.
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/26/20 showed the resident:
-Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15.
-Did not have any skin impairment.
-Required extensive staff assistance with bed mobility, transfers, and bathing.
-Required limited staff assistance with personal hygiene.
-Did not have behaviors.
-Was administered an antipsychotic medication seven out of seven days.
-Was administered an antianxiety medication seven out of seven days.
-Was administered an antidepressant medication seven out of seven days.
Record review of the resident's December 2020 Physician's Order Sheet (POS) showed:
-A physician's order for an outside wound care provider to evaluate and treat as needed dated 12/9/20.
-Buspirone HCl Tablet 5 milligram (mg), give 1 tablet by mouth at bedtime for anxiety dated 5/5/20.
-Hydroxyzine HCl Solution 25 milligram per milliliter (mg/ml), give 25 mg by mouth three times a day for Anxiety and/or Itching dated 5/17/20.
-Bupropion HCl ER (XL) Tablet Extended Release 24 Hour 150 mg, give 1 tablet by mouth one time a day for depression dated 5/6/20.
-Aripiprazole Tablet 15 mg, give 1 tablet by mouth one time a day related to Major Depressive Disorder, dated 5/6/2020.
Record review of the resident's electronic medical record showed:
-No documentation of the outside wound care provider's evaluation or weekly treatment records.
-No documentation of a monthly medication review by the facility pharmacist for 4/20, 5/20, 6/20, 7/20, 8/20, 9/20, and 10/20.
-No documentation of the resident's physician visits between March 2020 - January 2021.
Record review of the resident's Order Note dated 12/9/20 showed an outside wound care provider had seen the resident and had new wound care orders.
-NOTE: the facility was unable to provide the outside wound care provider's visit documentation that included the status of the resident's wounds.
Record review of the resident's Interdisciplinary Team (IDT) Note dated 12/9/20 showed a Nurse Practitioner (NP) from an outside wound care provider.
-NOTE: the facility was unable to provide the outside wound care provider's visit documentation that included the status of the resident's wounds.
Record review of the resident's January 2021 POS showed a physician's order for an outside wound care provider to evaluate and treat as needed dated 12/9/20.
During an interview on 1/15/21 at 10:05 A.M., Registered Nurse (RN) F said:
-When the pharmacist makes a recommendation, he/she gives it to the MDS person or the Assistant Director of Nursing (ADON) for review and follow-up.
-He/She did not have access to the pharmacist's monthly review to know what recommendations were made, if any, or if the recommendations were addressed by the resident's physician.
During an interview on 1/15/21 at 11:38 A.M., the Social Service Director (SSD) said:
-The facility changed pharmacy's in October 2020.
-The old pharmacy would send the monthly pharmacy review and any recommendations to the DON.
-He/She was not able to access the monthly pharmacy reviews that were sent to the previous DON.
-The facility was attempting to contact the previous DON and the previous pharmacy for those records.
During an interview on 1/19/21 at 11:15 A.M., Registered Nurse (RN) A said:
-The resident was seen by an outside wound care provider for his/her wounds.
-He/She did not have access to the resident's outside wound care provider's visit documentation.
-He/She thought that information may go to the Director of Nursing (DON).
-He/She did not have access to notes or documentation from the outside wound care provider.
-He/She thought the monthly drug regimen review was sent by the pharmacist to the DON.
-Physician visits should be scanned by medical records into the resident's electronic medical record.
During an interview on 1/19/21 at 1:59 P.M., the Assistant Director of Nursing (ADON) said:
-An outside wound care provider saw the resident each week.
-He/She could not locate the resident's outside wound care provider documentation.
-He/She thought the documentation may have gone to the previous DON.
-Staff did not have access to the outside wound care provider documentation.
-Usually documentation from an outside provider would go to medical records and scanned into the resident's electronic medical record.
-The monthly pharmacy drug regimen review was sent to the DON each month.
-He/She did not have access to the monthly drug regimen review.
-He/She would have to contact the resident's physician to obtain any visit notes between March 2020 to current.
-The facility did not have documentation of the resident's physician progress notes.
-Physician progress notes should have been scanned into the resident's electronic medical records.
2. Record review of Resident #42's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including urinary tract infection, pain, diabetes, dementia without behavioral disturbance, high blood pressure, anxiety disorder, obesity, vitamin deficiency, depression and other specified disorders of adult personality and behavior.
Record review of the resident's MDS dated [DATE], showed:
-The resident's BIMs was 15 out of 15 showing he/she had no cognitive incapacities.
-The resident had no mood, behaviors or psychosis/delirium.
-The resident needed extensive assistance with transfers and physical assistance with bathing needed, but no assistance noted with dressing grooming eating.
-The resident was always incontinent.
-The resident had no infections during the lookback period.
-The resident was not taking any antibiotics during the lookback period.
Record review of the resident's Nursing Notes showed:
-9/14/20-at 8:15 A.M., the resident was outside on a smoking break and told other peers he/she did not feel well. He/She complained of being tired and was speaking slowly with his/her eyes closed. Staff brought the resident in and took the resident's oxygen level and it was at 87 percent (normal oxygen saturation level should be above 90%). Staff rushed the resident to his/her room and placed him/her on oxygen, placed him/her in bed and lifted his/her feet. The resident's blood pressure was 73/35 (Normal should be 120/70) and the resident was groggy, but able to respond to questions. Staff called for an ambulance and checked his/her oxygen levels again (it was at 89 percent) and the resident became increasingly more conversational. Oxygen was decreased when the resident's oxygen level reached 98 percent. The ambulance transported the resident to the hospital of the resident's preference.
-9/16/20-the resident was readmitted to the facility from the hospital. He/She was alert and oriented. His/Her vital signs (temperature, blood pressure, respirations, pulse) were stable and he/she was self-propelling in his/her wheelchair. The resident received and antibiotic for treatment of a urinary tract infection.
-10/11/20- the nurse was called by staff to evaluate the resident out in courtyard where he/she was smoking. Upon arrival, the resident was sweating heavily and pale. He/She was responsive when his/her name was called, but appeared lethargic and was keeping his/her eyes closed. The resident stated he/she was having abdominal pain from constipation. His/Her vital signs were oxygen at 94 percent on room air, respirations were 16 and shallow, temperature was 95.2 (normal should be 98.6), blood sugar was 245 (normal should be below 150), heart rate was 98, and blood pressure was 80/40. The ADON notified the resident's physician and received orders to provide fluids for hydration and to obtain a lab for presence of urinary tract infection. The resident was not cooperative and at 11:14 A.M., the ambulance was called to transport the resident to the hospital, and ambulance was called to transport resident to the hospital.
-10/13/20- the resident returned to the facility from the hospital. He/She was alert and oriented without any distress. His/her diagnosis was urosepsis (a condition that develops from a urinary tract infection that has not been treated). His/He physician, pharmacy and DON was notified of the resident's re-admission and admitting orders.
-12/6/20 the resident became unresponsive outside during smoke time, the resident was in his/her wheelchair upon nursing intervention, the resident opened his/her eyes and responded. He/She said he/she was not feeling good. The resident's blood pressure was 74/32 on the first reading, and the second reading was 83/42. The resident's hands were cold from being outside and his/her oxygen level was not registering. Nursing staff sent the resident to the hospital via ambulance. Nursing staff notified the Nurse Practitioner, DON and the resident's responsible party.
-12/8/20-the resident returned to the facility from hospital and was alert and oriented. He/She denied pain and his/her vital signs were within normal limits.
Record review of the resident's electronic record showed there was no documentation of any physician's notes in the resident's medical record.
Observation and interview on 1/11/21 at 10:44 P.M., showed the resident was sitting in his/her wheelchair eating a meat snack. He/She was dressed for the weather and was alert and oriented to person, place and time. He/She said:
-He/She was independent with bathing, dressing, grooming, transferring and toileting.
-He/She currently had a yeast infection (a fungal infection that causes irritation, discharge and itchiness of the vagina).
-He/She had been to the hospital for recurrent urinary tract infections (and has a history of urinary tract infections).
-He/She had only connected with his/her physician through teleconference during the pandemic.
During an interview on 1/15/21 at 12:20 P.M., Social Service Designee said:
-They were not able to find any physician's notes in the resident's medical record.
-The resident changed physicians in June/July 2020 and his/ her new physician had not submitted any notes from telehealth visits that they were able to locate, but they were contacting the physician's office to see if they could have them sent over to the facility.
-At 2:00 P.M., two physician's notes were faxed to the facility and copies of the notes were provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
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 to documentation and monitoring for ongoing hospice care (a ...
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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 to documentation and monitoring for ongoing hospice care (a type of health care that focuses on comfort care of a terminally ill resident) visit and communication with hospice staff and failed to obtain pertinent documentation of the the delivery of hospice care services for one sampled resident (Resident #27) out 19 sampled residents. The facility census was 62 residents.
Review of the facility Hospice Services Policy and Procedure revision on 11/17/17 showed:
-Hospice services staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available for all interdisciplinary staff to access.
-Facility licensed personnel will be responsible to notify hospice service coordinator in event of change of resident condition and prior to transfer to another facility.
-All treatment and services are documented in accordance with the facility's medical record policies and nursing procedures.
Review of the facility's undated Medical Records Policy and Procedure showed:
-The facility was to ensure that a complete accurate and legal record the resident care maintained. The resident's medical record is readily accessible systematically organized to provide a medium, of communication among health care professional involved in the resident care and to facilitate retrieval and compilation of information.
-Record will be audited as needed to assure compliance. Reports of audits will be provided to the Director of Nursing (DON)and to other disciplines as applicable.
-Physician,nursing staff and other health involved in the resident's care will be responsible for making prompt appropriate entries into the resident's record and authenticating them with date, signature and title.
-Respite care records follow the standard facility policy, procedures and forms she be used for all admissions. transfer and discharge.
-DON and medical records personal shall assure that the medical records are maintained in accordance with the facility policies and procedures, and applicable federal and state regulations.
-Nursing documentation are in the nurse's records of the provision of and response to nursing care will be made on the nurses notes record and other specialized nursing forms as appropriate by a licensed and unlicensed nursing personnel.
-Monthly nursing progress notes will be written by licensed nursing personnel.
1. Record review of Resident #27's admission Face Sheet showed the resident was admitted to the facility on [DATE] had diagnoses including:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-History of cancer of the cervix.
-Was on Hospice services (end of life or chronic health palliative care services)
Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 5/18/20 showed the resident:
-Brief Interview for Mental Status (BIMS) score of 5 out of 15 and was severely cognitive impaired.
-While at the facility was placed on hospice services.
-Was able to make his/her own need known and able to understand others.
-Required extensive assistant of one staff for Activity of Daily Living (ADL).
Record review of the resident's Hospice Collaboration Log binder showed:
-Had two documented hospice visits in November on 11/19/20 and 11/25/20.
-No other documentation found for hospice service visit in the resident's hospice binder before 11/19/20 or after 11/25/20.
Record review of the resident's Quarterly MDS dated [DATE] showed the resident:
-Had a BIMS score of 5 out of 15 and was severely cognitive impaired.
-Was able to make his/her own need known and able to understand others.
-Required extensive assistant of one staff for Activity of Daily Living (ADL)
-No documentation related to resident on hospice services.
Record review of the resident's Hospice Care Plan reviewed 12/9/20 showed:
-The resident on hospice service for a terminal condition related to a diagnosis of senile degeneration of the brain.
-The hospice aide was to visit per scheduled days.
-Hospice provided Registered Nurse (RN) support per scheduled days.
-The facility were to maintain good communication with Hospice staff.
Review of the resident's Point Click Care (PCC) medical records showed the resident had no faxed or scanned hospice documentation related to the resident's completed hospice care visit.
Record review of the resident's progress notes from 11/1/20 to 1/15/21 showed:
-No documentation was found in the resident's progress notes, relate to when hospice staff was on site to provide hospice care services for the resident.
-No documentation was found for ongoing collaboration and communication between the facility staff and hospice staff during the resident's hospice care visit.
Record review of the resident's Physician Order Sheet (POS) dated 1/1/21 to 1/31/21 showed a physician's order for the resident to receive hospice services.
During an interview on 1/13/21 at 11:20 A.M., Certified Nursing Assistant (CNA) B said the resident was on hospice services and that hospice was making visits to see the resident.
During an 1/14/21 at 10:05 A.M., RN A said :
-The resident was no longer on hospice services, he/she was not sure the date of discharge from hospice.
-He/She said the business office could verify the resident discharge date .
During an interview on 1/14/21 at 10:10 A.M., the Business Office Manager (BOM) said:
-The resident remained on hospice services according to PCC.
-If the resident had been discharged from hospice services, then he/she would have had a dis-enrollment letter .
-The resident was initially admitted to hospice on 5/11/20.
-He/She was going to call the hospice agency to verify and obtain copies of the hospice visit.
During an interview 1/14/21 at 10:35 A.M., the BOM said:
-The resident was on hospice services and he/she had requested copy of the resident's hospice notes from 11/2020 to 1/14/21.
-Hospice staff had reported the resident's last hospice visit was on 1/4/21.
Record review of faxed copy of resident's Hospice Visit Notes showed:
-The facility had received faxed copy of the hospice notes on 1/14/21 at 10:47 A.M.
-The resident's hospice visit documentation was not in the resident's medical records prior.
-The facility had received copies of the resident's hospice visit notes from 11/1/20 to 1/4/21.
-The resident's last hospice care visit at the facility was on 1/4/21.
During an interview on 1/19/21 at 9:50 A.M., RN B said:
-The hospice staff communicate verbally with the facility nursing staff of any resident's treatment changes and change in condition of the resident.
-Hospice staff should document the visit in the resident's hospice binder chart.
-He/She was not aware of who be responsible for or if anyone had completed documentation by hospice staff after a hospice visit.
-The nursing staff would only document in resident's record if they had been informed by hospice staff of any new concerns for the resident, a change of condition, or new orders were received by hospice staff.
-He/She was not aware of the facility policy for monitoring resident's medical record and how or who would be responsible for ensuring to obtain ongoing documentation of resident's outside community care services, including hospice.
During interview on 1/19/21 at 1:59 P.M., the Assistant Director of Nursing (ADON) said:
-The facility staff should had been completing chart audits of the resident's medical records, but due to the turnover of DON, the facility had not been monitoring the resident medical records.
-Nursing management should be monitoring to ensure resident's have documentation of hospice services notes.
-He/she would expect hospice staff to document their visit in the resident hospice binder and facility medical records would scan any other hospice visit progress notes into the resident medical record.
-Front line staff do not review the documentation received until it had been scanned into the resident's medical record.
-He/She would expect to see ongoing facility nursing staff notes for resident's hospice visit that would include, something like seen by hospice at the facility today and any findings of the visit that had been communicated by hospice care staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to maintain a safe and sanitary environment in one non-resident room adjacent to a hallway and the Main Dining area by allowing ceiling tiles an...
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Based on observation and interview, the facility failed to maintain a safe and sanitary environment in one non-resident room adjacent to a hallway and the Main Dining area by allowing ceiling tiles and walls to become dampened to the point of having a visible black substance appearing to be mold growth on them. This deficient practice had the potential to affect numerous residents, visitors, and staff who passed through, used, or worked in the two areas nearby. The facility census was 62 residents with a licensed capacity for 120.
1. Observations during the facility Life Safety Code room inspections with the Interim Maintenance Director (IMD) on 1/12/21 at 2:41 P.M. showed the following in the Conference room across from the Main Dining room:
-One discolored 2 foot (ft) by 4 ft ceiling tile with numerous black splotches on it was sagging down from the ceiling tile grid.
-One discolored ceiling tile with black splotches on it was broken apart in a pile on the floor next to the east wall baseboard.
-Large black streaks and stains were on the wall above the baseboard on both sides of the northeast corner.
During an interview on 1/12/21 at 2:45 P.M., the IMD said the following:
-The dark patches on the ceiling tiles and on the walls could be black mold.
-He/She would have the tiles disposed of and use an anti-mold and mildew primer to paint the walls.
-He/She was filling in from another facility and unsure how long the tiles and walls had been in that condition.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to follow facility policies and procedures for checking the employee disqualification listing (EDL) and completing the Nurse Aide Registry Che...
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Based on interview and record review, the facility failed to follow facility policies and procedures for checking the employee disqualification listing (EDL) and completing the Nurse Aide Registry Check within a timely manner and in accordance with state requirements prior to employing eight of ten employees sampled for the EDL screening and five of ten employees sampled for the Nurse Aide Registry screening. The facility census was 62 residents.
Record review of the facility's Abuse Prevention and Reporting revised on 12/10/18, showed regarding pre-employment screening of potential employees:
-The facility will not knowingly employ any individual convicted of resident abuse, neglect, exploitation, mistreatment, or misappropriation of resident property.
-This facility will not knowingly hire any staff with a disciplinary action in effect against their license by a state licensing body that results from a finding of abuse, neglect, exploitation, mistreatment or misappropriation of resident property.
-All potential employees will be screened for a history of abuse, neglect, or mistreatment of patients during the hiring process. It will consist of, but not limited to the following:
--State licensing authorities
--State Nurse Aide Verification
--Reference checks from previous/current employers
--Criminal Background checks of all professional staff
1. Record review of employee records on 1/19/21, showed:
-Certified Nursing Assistant (CNA) E was hired on 6/30/20; documentation showed the facility staff did not check the EDL or Nurse Aide Registry.
-CNA G was hired on 7/11/19; documentation showed the facility staff did not check the EDL or Nurse Aide Registry.
-CNA H was hired on 6/29/20; documentation showed the facility staff did not check the EDL.
-CNA J was hired on 7/24/20; documentation showed facility staff did not check the EDL.
-CNA K was hired on 3/13/20; documentation showed facility staff did not check the EDL.
-CNA L was hired on 8/12/20; documentation showed facility staff did not check the EDL.
-Registered Nurse (RN) F was hired on 12/21/20; documentation showed the facility staff did not check the EDL or Nurse Aide Registry.
-Licensed Practical Nurse (LPN) B was hired on 1/28/20; the facility staff did not check the EDL.
-Housekeeping Aide A was hired on 1/7/20; the facility staff did not check the EDL or Nurse Aide Registry.
-Dietary Aide A was hired on 1/8/21; the facility staff did not check the EDL or Nurse Aide Registry.
During an interview on 1/19/21 at 8:44 A.M., the Human Resources Manager said:
-He/She was hired in July and came from the state of Kansas and did not know the additional requirements needed for the state of Missouri regarding checking the Employee Disqualification Listing.
-He/She was unaware that the Nurse Aide Registry check should be completed on all employees.
-He/She would ensure the EDL and Nurse Aide Registry was checked on all newly hired employees going forward.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident's #5 face sheet showed he/she was admitted to the facility on [DATE] with a diagnoses of major Depr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident's #5 face sheet showed he/she was admitted to the facility on [DATE] with a diagnoses of major Depressive Disorder.
Record review of the resident's MRR dated 3/16/20 showed:
-Pharmacist requested a gradual dose reduction (GDR) for Remeron. The resident currently received Remeron 30 mg by mouth at bedtime for depression.
-Please assess medical risk versus benefit and if your patient may benefit from a gradual dose reduction.
Record review of the resident's medical records showed no documentation MRRs were performed from April 2020 until November 2020.
Record review of the residents January 2021 POS showed:
-He/she was ordered Remeron 30 mg by mouth at bedtime dated 12/14/20 .
-No documentation the resident's physician had addressed the pharmacist's recommendation for a gradual dose reduction dated 3/16/20.
5. Record review of Resident's #6 face sheet showed he/she was admitted to the facility on [DATE] with a diagnoses of major Depressive Disorder.
Record review of the resident's medical records showed no MRRs were performed from April 2020 until November 2020.
Record review of the resident's MRR dated 12/22/20 showed:
-Pharmacist requested Gradual Dose Reduction of Lexapro from 10 mg to 5 mg.
-No record of Doctor doing GDR or the rational as to why it is not clinically appropriate not to do the GDR.
-No notes as to if the doctor was informed of the requested GDR.
Record review of the residents January 2021 POS dated showed:
-An order for Lexapro 10 mg give 1 tablet by mouth one time day.
-No documentation the resident's physician had addressed the pharmacist's recommendation for a gradual dose reduction dated 12/22/20.
6. During an interview on 1/15/21 at 10:05 A.M., Registered Nurse (RN) F said:
-When the pharmacist makes a recommendation, he/she gives it to the MDS person or the Assistant Director of Nursing (ADON) for review and follow-up.
-He/She did not have access to the pharmacist's monthly review to know what recommendations were made, if any, or if the recommendations were addressed by the resident's physician.
During an interview on 1/15/21 at 11:38 A.M., the SSD said:
-The facility changed pharmacy's in October 2020.
-The old pharmacy would send the monthly pharmacy review and any recommendations to the DON.
-The current pharmacy sent recommendations to the previous Director of Nursing (DON) and the facility could not access those records at that time.
-The facility was not able to provide documentation the pharmacy reviews were addressed by the resident's physician.
-He/She was not able to access the monthly pharmacy reviews that were sent to the previous DON.
-The facility was attempting to contact the previous DON and the previous pharmacy for those records.
During an interview on 1/15/21 at 12:30 P.M., RN B said:
-Usually if the pharmacist has a recommendation, the nurse will notify the physician by phone and either the physician will write an order and follow the pharmacist's recommendation in response to the recommendation, or the physician will tell them that he/she is not going to follow the pharmacist's recommendation and they will continue the physician's orders as written and make no changes.
-They should document the physician's response in the nursing notes.
-They usually did not fax or scan a copy of the Drug Regimen Review recommendation form to the physician for his/her signature or for acknowledgement and response to the pharmacist's recommendations.
During an interview on 1/19/21 at 11:10 A.M., RN A said:
-Pharmacy recommendations would go to the DON for review and follow-up.
-He/She had no idea if the pharmacy reviews were followed or addressed with the resident's physician.
-He/She did not have access to see what the pharmacist's recommendations were.
During an interview on 1/19/21 at 2:00 P.M., the ADON said:
- Pharmacy recommendations were being sent directly to the previous DON.
-The DON would be responsible for ensuring that the pharmacist's recommendations were looked at monthly, and was also responsible for forwarding them to the Physician.
-No one was auditing the resident medical records to ensure that the reviews were being done.
-The process is that the DON should contact the Nurse Practitioner or physician and notify them of the pharmacist's recommendation. If the physician did not want to follow the recommendation, they would send this information to the pharmacist and they should get an order stating that the recommendation would not be followed and give a rationale for why they are not following the recommendation.
-It should be documented in the resident's medical record.
-He/She will be responsible for this process temporarily until the new DON is able to take the responsibility and they are in process of notifying the pharmacist to change the contact for receiving the Drug Regimen Reviews.
-They were not currently doing Monthly Medication Reviews.
-The facility had changed Pharmacies.
-The facility was trying to obtain the records from the Director of Nursing (DON) who no longer worked at the facility.
3. Record review of Resident #41's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow form the lungs making breathing difficult).
-Fracture of the lower end of the left humerus (an injury to the upper bone that connects the shoulder to the elbow).
-Other idiopathic peripheral autonomic neuropathy (an unknown cause of nerve damage).
-Hypertension (high blood pressure).
-Hyperlipedemia (a condition in which there is a high level of fat in the blood).
-Pneumonia (infection that inflames air sacs in one or both lungs which may fill with fluid).
-Major depressive disorder (a group of conditions associated with the elevation or lowering of a person's mood).
-Altered mental status (general changed in brain function, such as confusion, memory loss, loss of alertness, disorientation, and defects in thought or judgement).
-Insomnia (the inability to fall asleep and stay asleep).
Record review of the resident's Physician's Order Sheet dated November 2020 showed orders for:
-Atorvastatin Calcium (a medication used to lower a person's cholesterol and prevention of heart disease) tablet 20 milligram (mg) one tablet to be taken by mouth one time a day for shortness of breath dated 6/3/20.
-Coreg tablet (a medication used to treat high blood pressure and heart failure) 6.25 mg one tablet to be taken two times a day for heartburn, hold the medication if the resident's blood pressure was less than 100/60 or heart rate was less than 55, call the Physician, dated 8/28/20.
-Neurontin capsule (a medication used to treat seizures and nerve pain) give 800 mg to be taken by mouth three times a day related to unspecified fracture of lower end of left humerus dated 9/15/20.
Record review of the resident's Pharmacy recommendations to staff dated 11/18/20 showed:
-The Pharmacist had made the following recommendation to the unassigned Physician:
-Atorvastatin should be updated to say Hyperlipidemia and remove shortness of breath.
-Coreg should be updated to say hypertension and remove heartburn.
-Neurontin should be updated to say neuropathy remove the verbiage around femur fracture.
Record review of the resident's Physician's Order Sheet dated December 2020 showed the recommended changes were not done.
Record review of the resident's POS for November 2020, did not show the Physician had sign the sheets verifying he/she agreed with them.
Record review of the resident's POS for December 2020, did not show the Physician had sign the sheets verifying he/she agreed with them.
Record review of the resident's POS for January 2021, did not show the Physician had sign the sheets verifying he/she agreed with them.
Record review of the resident's Physician's Order Sheet dated January 2021 showed:
-The Neurontin order was changed on 12/3/20.
-The orders for Atorvastin and Coreg were changed on 1/14/21.
2. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses:
-Peripheral vascular disease (inadequate blood flow to the extremities).
-Non-pressure chronic ulcer (open wound) of the lower leg.
-Anxiety disorder.
-Major depressive disorder.
-Schizoaffective disorder.
-Sleep apnea (a condition that occurs when the airway becomes narrow as the muscles relax during sleep which reduces oxygen in the blood and causes arousal from sleep).
-Congestive Heart Failure (CHF - disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body).
Record review of the resident's care plan dated 6/26/20 showed:
-Was prescribed antidepressant, antianxiety, and psychotropic medications.
-Consult with pharmacy and the resident's physician to attempt a dose reduction when clinically appropriate at least quarterly.
-Had decreased cardiac output due to CHF and directed staff to monitor his/her vital signs.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15.
-Required extensive staff assistance with bed mobility, transfers, and bathing.
-Required limited staff assistance with personal hygiene.
-Did not have behaviors.
-Was administered an antipsychotic medication seven out of seven days.
-Was administered an antianxiety medication seven out of seven days.
-Was administered an antidepressant medication seven out of seven days.
Record review of the resident's December 2020 POS showed:
-A physician's order for an outside wound care provider to evaluate and treat as needed dated 12/9/20.
-Buspirone HCl Tablet 5 milligram (mg), give 1 tablet by mouth at bedtime for anxiety dated 5/5/20.
-Hydroxyzine HCl Solution 25 milligram per milliliter (mg/ml), give 25 mg by mouth three times a day for Anxiety and/or Itching dated 5/17/20.
-Bupropion HCl ER (XL) Tablet Extended Release 24 Hour 150 mg, give 1 tablet by mouth one time a day for depression dated 5/6/20.
-Aripiprazole (Ability) Tablet 15 mg, give 1 tablet by mouth one time a day related to Major Depressive Disorder, dated 5/6/2020.
-Trazodone HCl Tablet 100 mg, give 100 mg by mouth at bedtime related to sleep apnea dated 5/17/20.
-Metoprolol Tartrate Tablet 100 mg, give 0.5 tablet by mouth two times a day with for CHF dated 5/20/20.
Record review of the resident's electronic medical record showed:
-No documentation of a monthly medication review by the facility pharmacist for 4/20, 5/20, 6/20, 7/20, 8/20, 9/20, and 10/20.
Record review of the resident's pharmacy note in his/her electronic medical record dated 11/18/20 showed Medication Record Review (MRR) review, please see pharmacy recommendations.
Record review of the resident's medical record showed no documentation of the pharmacist recommendation dated 11/18/20 or if the recommendation had been addressed by the resident's physician.
Record review of the resident's pharmacy note in his/her electronic medical record dated 12/21/20 showed Medication Record Review (MRR) review, please see pharmacy recommendations.
Record review of the resident's medical record showed no documentation of the pharmacist recommendation dated 12/21/20 or if the recommendation had been addressed by the resident's physician.
Record review on 1/15/21 of the resident's pharmacy monthly medication record review showed:
-On 11/18/20 the pharmacist recommended adding parameters to the resident's Metropolol. This was not updated until 1/14/21.
-On 12/21/20 the pharmacist recommended a gradual dose reduction of the resident's Abilify 15 mg daily. This had not been addressed as of 1/15/21.
-On 12/22/20 the pharmacist recommended updating the diagnosis for the resident's Trazadone to remove sleep apnea and add insomnia. This was not updated until 1/14/21.
Based on interview and record review, the facility failed to ensure pharmacy Drug Regimen Reviews (DRR) were completed and in the resident's medical record monthly and failed to ensure the resident's physician responded to pharmacy recommendations and the response were documented in the resident's medical record for five sampled residents (Resident #42, #13, #41, #5, and #6) out of 19 sampled residents. The facility census was 62 residents.
Record review of the facility's policy titled Pharmacist Medication Review dated 11/28/17 showed:
-The Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once per calendar month for each resident residing in certified areas of skilled long term care facility.
-The consultant Pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist. Federally mandated standards of care as well as other applicable standards serve as the basis for review to ensure that a resident's medications are promoting or maintaining the resident's highest level of function in congruence with the resident's therapeutic goals and to identify clinically significant risks and/or adverse medication reactions.
-The review of the medication regimen will include all medications currently ordered, including medications that are ordered as needed. The review will incorporate information from the resident's chart concerning the resident's condition, monitoring side effects, potential for drug interactions, psychotropic medication review, including considerations for dose reduction/optimal dosing, review of the medication administration records and ancillary documentation such as the physician's progress notes, nursing notes and laboratory test results.
-The Consultant Pharmacist will report any irregularities in writing to the attending physician, the Medical Director and the Director of Nursing for follow up. The written documentation will include minimally, the resident's name, the relevant drug and the identified irregularity.
-The Director of Nursing or designee will notify the attending physician of recommendations either in person, by telephone, fax, or other secure system of notification within three business days of receiving the report from the Consulting Pharmacist. If no response is received from the attending physician within three business days following notification, the Director of Nursing will make a second attempt to notify the physician. If the attending physician does not respond after a second attempt, the Medical Director will be notified of the recommendation. The Director of Nursing will notify the attending physician of irregularities that require urgent action the same business day that notification was communicated. If unable to notify the attending physician, The Medical Director will be notified.
-In addition to the written communication intended for the attending physician, the Medical Director and the Director of Nursing, medication regimen review documentation of completed consultation will be maintained in the resident's clinical record. The documentation should include whether or not any apparent irregularities were found, the pharmacist's signature and title and date the review was performed.
-The facility is responsible for ensuring all clinical records are available for review.
-The Consultant Pharmacist is available to consult with the prescribing physicians, Medical Director or nursing staff regarding recommendations resulting from the medication regimen review. It is the responsibility of the facility to ensure that each of the recommendations result in a response by either a physician or nurse as appropriate. The attending physician/Medical Director or designee should document in the medical record that the identified irregularity has been reviewed subsequent action taken, if required. In the event where no change will be made as a result of the identified irregularity, the physician/Medical Director or designee should document rationale in the medical record.
-The documentation of completed medication regimen review should be kept as part of the resident's record to reflect at least twelve months of review.
1. Record review of Resident #42's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including urinary tract infection, pain, diabetes, dementia without behavioral disturbance, high blood pressure, anxiety disorder, obesity, vitamin deficiency, cirrhosis of the liver (a liver disease marked by degeneration of the cells, inflammation and thickening of the liver tissue), depression and other specified disorders of adult personality and behavior. The Face Sheet showed the resident was his/her own responsible party, but he/she had an emergency contact who was also the resident's power of attorney.
Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/14/20, showed:
-The resident's cognition score was 15-showing he/she had no cognitive incapacities.
-The resident had no mood, behaviors or psychosis/delirium during the lookback period.
-The resident needed extensive assistance with transfers and physical assistance with bathing needed, but no assistance noted with dressing grooming eating.
-The resident was always incontinent.
-The resident had no infections and was not receiving any antibiotics during the lookback period.
-The resident diagnoses did not include any psychotic disorders.
-The resident received anti-psychotic and anti-depressant medications administered during the lookback period.
Record review of the resident's Physician's Order Sheet (POS) dated January 2021, showed physician's orders for:
-Nystatin 100000 unit/gram (gm) cream apply topically to vaginal area twice daily (11/9/20).
-Famotidine Tablet 20 milligrams (mg) one time a day for GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD- a digestive disease in which stomach acid irritates the lining of the food pipe lining) (10/29/20).
-Magnesium Oxide Tablet 400 mg give once daily for nutritional supplement (10/29/20).
-Multivitamin Tablet give one time a day for nutritional supplement (10/29/20).
-Sitagliptin Phosphate Tablet 100 mg give once daily for diabetes (10/29/20).
-Milk of Magnesia Suspension 400 mg/5 milliliters (ml) give 30 ml every 24 hours as needed for constipation daily (10/13/20).
-Quetiapine Fumarate Tablet 100 MG Give 100 mg one time daily for anxiety disorder (10/13/20).
-Thiamine give 100 mg once daily for by mouth one time a day for cirrhosis of the liver (10/13/20).
-Glimepiride Tablet 4 mg once daily for diabetes (10/13/20).
-Duloxetine 60 mg give at bedtime for depression (10/13/20).
-Farxiga 10 mg give once daily for diabetes (10/13/20).
-Atorvastatin 20 mg give daily for high blood pressure (10/13/20).
-Tylenol Extra Strength Tablet 500 mg give two tablets every 6 hours as needed for pain (10/13/20).
Record review of the resident's Pharmacy Reviews (Drug Regimen Review) showed the following:
-There were no Drug Regimen Reviews completed and in the resident's medical record from January 2020 to October 2020.
-On 11/18/20 the Drug Regimen Review showed the Pharmacist requested the resident's physician to clarify the physician's order for Quetiapine as one of the specific conditions listed as an accepted diagnosis. The specific diagnoses included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Schizophrenia (a long-term mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder such as depression or bipolar disorder), or Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). The document did not show that the Physician responded to the recommendation and the document was not signed, showing the physician had reviewed or acknowledged the recommendation.
Record review of the resident's Progress Notes showed from 11/1/20 to 12/27/20 there was no documentation showing the resident's Physician was notified of the Pharmacist's recommendation or that the physician had responded to the recommendation (either to agree or disagree with the recommendation). The note dated 11/18/20 showed a pharmacy note stating please see pharmacy recommendations.
Record review of the resident's Medical Record showed there was no documentation showing there were any Drug Regimen Reviews completed from January 2020 to October 2020 and there was no documentation showing that the physician acknowledged receiving the Pharmacist's recommendation on 11/18/20 and responded to it.
Record review of the resident's Physician Notes showed there were no physician's notes in the resident's medical record.
During an interview on 1/15/21 at 12:20 P.M., the Social Service Designee (SSD) said:
-The resident changed physicians in June/July 2020 and his/her previous physician had not submitted any notes from any telehealth visits that they were able to locate.
-They had not obtained the resident's current physician's notes until today (two notes were faxed to the facility).
-They were unable to locate any of the resident's Drug Regimen Reviews completed until 11/18/20.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure inhalers and medication vials were dated when opened; failed to ensure expired medications were removed from the medic...
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Based on observation, interview, and record review, the facility failed to ensure inhalers and medication vials were dated when opened; failed to ensure expired medications were removed from the medication delivery system; and failed to ensure medications carts are locked and not left unattended by staff when they were unlocked. The facility census was 62 residents.
Record review of facilities Medication Storage policy dated 10/1/15 revised 7/2/19 showed:
-Facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors.
-Once any medication or biological package was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when medication had a shortened expiration date once opened.
-Facility should ensure that medications and biologicals that: (1) have an expired date on the label, (2) have been retained longer than recommended by manufacturer or supplier guidelines, or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier.
1. Observation on 1/11/21 at 12:10 P.M. of the East Hall showed one of the two medication carts were unlocked with medications inside. The medication cart was left unattended by staff.
Observation on 1/11/21 at 12:45 P.M. of the East Hall showed the treatment cart was in the hall, unlocked and unattended by staff. The nurse was in a resident room out of visual sight of the treatment cart.
Observation on 1/14/21 at 6:45 A.M. of the west Hall showed one of three medication carts in front of the nurses station was unlocked with medications in it. The medication cart was left unattended by staff.
Observation on 1/14/21 at 6:56 A.M. of the [NAME] hall nurse's medication cart showed:
-A half-empty bottle of Aspirin (an over-the-counter pain reliever) with an expiration date of 8/20 and marked as opened for resident use on 9/22/20.
-Four Albuterol inhalers (medication used to increase the movement of air in the lungs) opened with no dates of when they were opened.
-The medication cart unlocked and Registered Nurse (RN) B was behind the nurse's desk.
Observation on 1/14/21 at 7:15 A.M. of the west hall medication room refrigerator showed:
-One opened vial of Aplisol (a medication used as an aid in the diagnosis of tuberculosis) with no date on the vial when it was opened.
-A vial of Levimir (an insulin) with no date on the vial when it was opened.
During an interview on 1/14/21 at 7:24 A.M., RN B said:
-Expired medications should not be opened nor dispensed to residents.
-Expired medication should be removed from the medication delivery system.
-Medications should not be administered to a resident after it had expired.
-He/She did not know when the vial of Aplisol or Levimir had been opened.
-Medications should be dated when opened.
-The medication cart should be locked anytime he/she the cart is left unattended.
-Staff check the medication cart for expired medications daily.
Observation on 1/14/21 at 8:10 A. M. of the Certified Medical Technician (CMT) cart on the East hall showed:
-Two Combivent (medication used to increase the movement of air in the lungs) inhalers opened and not dated.
-One Symbicort (medication used to increase the movement of air in the lungs) inhaler opened and not dated.
-One Combivent inhaler opened, not dated as when opened, not in a manufactures box, and no label on the inhaler to show whom it belonged to.
During an interview on 1/14/21 at 815 A.M., CMT B said:
-Medications are to be dated when opened.
-Breathing inhalers are to be labeled, dated, and kept in manufactures box.
-Medication not in box or labeled should be destroyed.
During an interview on 1/19/21 at 2:31 P.M., the Assistant Director of Nursing (ADON) said:
-All multi-dose medications should be dated when opened.
-All medications should be dated when opened.
-No medication should be used past the expiration date.
-No medication that was expired should be given to residents, and that it should be destroyed.
-The night shift should be checking the medication carts nightly for expired medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional needs of residents in accordance with established national guide...
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Based on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional needs of residents in accordance with established national guidelines, and failed to have a basic ingredient in stock that is called for in many recipes. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 62 residents with a licensed capacity for 120 residents.
Record review of the undated Week at a Glance menus for weeks 1 through 4, provided by the DM, showed a variety of meals that met the nutritional needs of residents in accordance with established national guidelines. The lunch meal for week 2 that was supposed to be served was listed as chili mac with buttered peas and peaches with whipped topping.
1. Observations on 1/11/21 at 9:30 A.M. of the lunch meal preparation showed:
-The Day [NAME] preparing potato and hamburger casserole, mixed vegetables, and bread.
-No recipes were out and being followed during meal preparation.
-It could not be determined if any ingredients were missing, or if the appropriate amount of food was cooked to ensure accurate serving sizes.
During an interview on 1/11/21 at 9:35 A.M., the Dietary Manager (DM) said the following:
-The standard menu was not used for preparing meals as of yet.
-He/She and the Day [NAME] were just making up dishes from whatever was available on hand.
During an interview on 1/11/21 at 12:09 P.M., the Day [NAME] said the following:
-He/She had to make up their own recipe for the potato and hamburger casserole.
-The mixed vegetables would have turned out better if they had butter in stock.
During an interview on 1/12/21 at 9:09 A.M., the Day [NAME] said the following:
-There was still no butter available in stock for today's meals.
-No one had set the Salisbury steaks that were planned for lunch out to thaw, so he/she was going to substitute hamburger patties and add gravy and onions.
-They were also planning on having the mixed vegetables again today.
-Indicating essentially the same meal as the previous day.
2. Observations on 1/12/21 at 12:37 P.M. showed a test plate on a food tray had the hamburger with gravy and onions, mixed vegetables, and a slice of bread without any butter.
During an interview on 1/13/21 at 9:45 A.M., the DM said the following:
-He/She intended to start using pre-prepared menus and recipes that day at dinner.
-They expected to have all basic ingredients in stock that day as well because their food delivery was expected at noon.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain sanitary food serving utensils and preparation equipment; failed to ensure plastic cutting boards were in good condi...
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Based on observation, interview, and record review, the facility failed to maintain sanitary food serving utensils and preparation equipment; failed to ensure plastic cutting boards were in good condition to avoid food safety hazards; failed to separate damaged food stuffs; and failed to keep a ceiling vent and floor fan free of lint to prevent food contamination. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 62 residents with a licensed capacity for 120.
1. Observations during the kitchen inspection on 1/11/21 between 8:51 A.M. and 1:15 P.M. showed the following:
-A microwave had food splatters on the interior walls, top, and inside of door.
-A toaster had an abundance of crumbs in the bottom.
-A white cutting board was deeply scored to the point of plastic bits hanging off it.
-A white handled spatula had dark brown streaks of an unknown substance dried and peeling off the metal blade.
-On a can dispenser rack in the Dry Storage room there was a 6.61 pound (lb) can of mandarin oranges with a dent on the bottom edge and a 115-ounce can of baked beans severely dented on the bottom and side.
-There was an onion, a butter pod, pieces of paper and plastic, and miscellaneous food debris on the floor of the walk-in refrigerator.
-There were pieces of paper and plastic, chunks of ice, and a dessert cup on the floor of the walk-in freezer.
-The manual can opener had bits of paper on the blade.
-A ceiling vent between an oven and food preparation table had an accumulation of stringy dust, dirt, and debris on the louvers (A set of angled slats or flat strips fixed at regular intervals in a vent, shutter, or screen to allow air to pass through.).
-A large floor fan by a set of double doors had an excessive build-up of dust, dirt, and debris on the blade guards.
-There was an empty cardboard container and a plastic cup under the steam table.
2. Observations during the kitchen inspection on 1/12/21 between 8:54 A.M. and 9:15 A.M. showed the following:
-The same two large dented food cans were on the can dispenser in the Dry Storage room.
-An abundance of crumbs were still in the bottom of the toaster and food splatters remained inside the microwave.
-The walk-in floors continued to have miscellaneous food and trash debris on them.
-The ceiling vent and floor fan were still heavily laden with dust, dirt, and debris.
-The manual can opener had paper debris on the blade.
-The white-handled spatula had dried brown streaks peeling off the metal blade.
-The empty cardboard container and plastic cup continued to be under the steam table.
During an interview on 1/13/21 at 9:45 A.M., the Dietary Manager (DM) said the following:
-Either he/she or the cook would check food delivery items for damage and separate them for credit by the vendor.
-All dietary staff were responsible for cleaning food preparation equipment and utensils after meals and at the end of the day.
-The walk-in floors should be cleaned daily and a check-off sheet was being made for future cleanings.
-He/She would expect the ceiling vents and any fans to be clean to prevent dirt or dust particles from being blown onto the food.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed:
-Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
-In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
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 follow standard trash and garbage disposal practices to mitigate the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow standard trash and garbage disposal practices to mitigate the presence of common household pests (for example, bed bugs, lice, roaches, ants, mosquitoes, flies/gnats, mice, and/or rats), and failed to maintain an effective pest control program with measures to eradicate those pests when present. The facility's census was 62 residents with a licensed capacity for 120 residents.
1. Observations during the dining room and kitchen inspections on 1/11/21 between 8:51 A.M. and 2:10 P.M. showed the following:
-A roach was on the floor of the southeast dining room doorway to the Main Dining room and another one on the room's west wall.
-Gnats were hovering about a full trash can in the southeast dining room by the Kitchen double doors and another one by the room's west wall outlet.
-Two roaches were on the floor of the Main Dining room by a wall partition and another one was on top of the trash in the full white trash can by the single kitchen door.
-In the Kitchen there were three dead roaches on the floor next to the food preparation table by the stove.
-There was a roach crawling under a microwave on the food preparation table.
-There was a roach crawling on the wall above the 3-sink area.
-There was a roach crawling among papers on the square table next to the Dietary Manager's office.
-There was a roach crawling on the back of the top metal canopy of the steam table.
-There was a roach in the middle of the Main Dining room floor after it had just been mopped.
2. Observations on 1/12/21 between 8:44 A.M. and 11:45 A.M. showed the following:
-There was a roach crawling across the floor of the Main Dining room.
-There was a roach by a microwave on the sink counter in the Main Dining room.
-There was a roach crawling out from under the stove in the Kitchen.
-There was a roach in the hallway outside of the Main Dining room and another one inside the main dining room by a china cabinet.
-In resident room [ROOM NUMBER] there were several gnats flying about.
3. Observations on 1/12/21 at 1:22 P.M. showed a left over lunch plate of food left on a table in the Main Dining room with food debris on the floor next to it.
4. Observations on 1/12/21 at 1:36 P.M. showed the Receptionist in the front entrance common area swatting away at gnats while remarking, They're everywhere.
During an interview on 1/13/21 at 9:45 A.M., the Dietary Manager (DM) said the following:
-He/She had noticed the roach problem, which was why they were formulating a thorough kitchen-cleaning program.
-He/She believed the facility also had a pest control program already in place.
5. Observations on 1/13/21 at 2:09 P.M. showed three food trays (from lunch meal service) with plates of leftovers on them and two roaches crawling amongst them on the sink counter outside the Main Dining room kitchen door.
6. Observations on 1/14/21 at 8:51 A.M. showed two roaches on the floor by an overflowing trash can outside the main dining room kitchen door, and one on the side of the cabinet next to it.
During an interview on 1/14/21 at 11:21 A.M., the Administrator said the following:
-He/She was aware of the roach problem and they were taking steps to address it.
-The exterminator had been there three weeks ago and was coming the next day.
-Usually, the exterminator came once a month.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based interview and record review, the facility failed to establish and maintain competencies and skill sets of facility nursing staff for four out four sampled nurses. The facility census was 62 resi...
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Based interview and record review, the facility failed to establish and maintain competencies and skill sets of facility nursing staff for four out four sampled nurses. The facility census was 62 residents.
1. Record review of four Licensed Nurses employment files on 1/19/21 showed no competencies sign offs could not be produced for verification.
During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said:
-No competencies could be found for the nursing staff.
-He/She started working for the facility in November 2020.
-He/She had not provided any competencies or skills check offs since he/she started working for the facility.
-He/She could not locate any nursing competencies or skills check offs prior to November 2020.
-Training was poor prior to him/her working for the facility, and he/she had just started getting a training program developed.
During an interview on 1/19/21 at 11:57 A.M., the Administrator said:
-Nursing managers were responsible for ensuring competencies were done.
-He/She would expect competencies or skills check offs for all staff.
-There should be skill check off list for new employees.
-He/She was unaware that skills checks and competencies were not being done.
During an interview on 1/19/21 at 2:26 P.M., the Assistant Director of Nursing (ADON) said:
-A competency check list should be done upon hire and annually.
-As new skills are needed, an in-service should be given on how to perform the cares that are needed to care for residents.
-All staff should have received training annually on dementia and Alzheimer's.
-The Director of Nursing (DON) or ADON was responsible to ensure competencies and skills check offs were completed.
-The DON was responsible to audit the employee records to ensure the competencies and skills check off were completed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have a system in place to ensure a Certified Nursing Assistant (CNA's) received the required 12 hours in-service education based on perform...
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Based on interview and record review, the facility failed to have a system in place to ensure a Certified Nursing Assistant (CNA's) received the required 12 hours in-service education based on performance reviews annually for six CNAs out of six sampled. The facility census was 62 residents.
1. Record review on 1/19/21 of six CNAs employment file showed the required 12 hours in-service education hours competencies and/or skills sign offs could not be produced for verification.
During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said:
-The required 12 hours of CNA in-service education records could not be produced for verification.
-He/She started in working for the facility in November 2020.
-He/She could not find documentation of any CNA inservice education or skills check-offs prior to November 2020.
-He/She had not provided any CNA inservice education or skills check offs since November 2020.
-Training was poor prior to him/her coming to the facility, and he/she had just started getting a training program developed.
During an interview on 1/19/21 at 11:57 A.M., the Administrator said:
-There should be the required 12 hour in-service training for CNA's.
-Was unaware that the required in-service training was not being completed.
-Nursing managers were responsible to make sure the 12 hour in-service education was done.
During an interview on 1/19/21 at 2:26 P.M., the Assistant Director of Nursing (ADON) said:
-The 12 hour in-service education for CNA's should have been done.
-All CNA's were to have in-service training.
-The Director of Nursing (DON) was responsible to audit the CNAs employee records to ensure the staff had completed the appropriate trainings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0741
(Tag F0741)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide 12 hours of in-service training for the licensed nurses on dementia and behavioral health needs for four licensed nurses of four sa...
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Based on interview and record review, the facility failed to provide 12 hours of in-service training for the licensed nurses on dementia and behavioral health needs for four licensed nurses of four sampled. The facility census was 62 residents.
1. Record review of four Licensed Nurses employment file showed the required 12 hours of in-service training on dementia and behavioral health needs verification could not be produced.
During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said:
-He/She started working for the facility in November 2020.
-He/She had not provided the required 12 hours in-service training on dementia and behavioral health needs for the nursing staff since he/she started working for the facility.
-He/She could not locate any in-service training verification on dementia and behavioral health needs prior to November 2020.
-Training was poor prior to him/her working for the facility, and he/she had just started getting a training program developed.
During an interview on 1/19/21 at 11:57 A.M., the Administrator:
-There should be the 12 hour in-service training on Dementia and behavioral health needs for all nursing staff.
-Nursing management was responsible for this training.
-Was unaware that the required 12 hour in-services were not being done.
During an interview on 1/19/21 at 2:26 P.M., the Assistant Director of Nursing (ADON) said:
-The 12 hour in-service education for nursing on dementia and behavioral health needs should have been done.
-All nursing is to should have received training annually on dementia and behavioral health needs.
-Director of Nursing (DON) should have performed audits on in-services.
-Audits were not done this was the previous DON responsibility.
-The DON or ADON was responsible to ensure the 12 hours of dementia training were completed.
-The DON was responsible to audit the employee records to ensure the 12 hours of dementia training were completed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
Based on interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was...
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Based on interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 62 residents.
Record review of the facility's Inventory Control of Controlled Substances policy dated 11/28/12 and revised on 11/26/17 showed:
-Staff were to always participate in the counting of the controlled substances at the beginning and ending of your shift.
-Have partner to assist in the count.
-Sign name, time and date of completed count.
1. Record review of the facility's Controlled Drug Count sheet dated 11/9/20 - 11/20/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Five out of 26 opportunities were not signed by either the oncoming or off going staff.
Record review of the facility's Controlled Drug Count sheet dated 11/21/20 - 12/3/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Two out of 26 opportunities were not signed by either the oncoming or off going staff.
Record review of the facility's Controlled Drug Count sheet dated 12/4/20 - 12/16/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Ten out of 26 opportunities were not signed by either the oncoming or off going staff.
Record review of the facility's Controlled Drug Count sheet dated 12/17/20 - 12/29/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Nine out of 26 opportunities were not signed by either the oncoming or off going staff.
Record review of the facility's Controlled Drug Count sheet dated 12/30/20 - 1/11/21 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Six out of 26 opportunities were not signed by either the oncoming or off going staff.
Record review of the facility's Controlled Drug Count sheet dated 1/12/21 - 1/14/21 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Two out of 6 opportunities were not signed by either the oncoming or off going staff.
During an interview on 1/14/21 at 7:24 A.M., Registered nurse (RN) B said:
-The narcotics are counted at the beginning and end of each shift with the oncoming nurse and off going nurse.
-Both nurses sign the count sheet when the count has been completed to verify the count is correct.
During an interview on 1/19/21 at 2:31 P.M., the Assistant Director of Nursing (ADON) said:
-The oncoming and off going shifts should count the narcotics and sign the narcotics book each shift.
-The previous Director of Nursing (DON) was auditing this and they stopped auditing in December 2020.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 1/14/21 at 6:30 A.M., showed:
-The Human Resource (HR) Director entered the facility through the double doors ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 1/14/21 at 6:30 A.M., showed:
-The Human Resource (HR) Director entered the facility through the double doors from the outside into the foyer.
-He/She stood in line waiting to be screened for signs or symptoms of COVID.
-There was a receptionist at the desk who was screening people.
-There were new surgical masks on the receptionist's desk.
-The HR Director stood in the foyer for more than ten minutes without a mask on.
-There was one male resident sitting in a chair in the foyer looking out the doors.
-The HR Director went into his/her office which was located directly behind the receptionist's desk without a mask on.
Observation on 1/15/21 at 8:15 A.M., showed:
-CMT A walking down the hall between the East and [NAME] Halls without his/her mask pulled up over his/her nose and mouth.
-His/Her mask was down around his/her neck.
-He/She was within three feet of a resident.
-He/She talked to the resident for six minutes.
-The resident was wearing a facemask correctly.
During an interview on 1/15/21 at 8:45 A.M., RN E said:
-The staff has had a lot of education on when and what PPE was to be worn.
-There was enough PPE.
-Anyone entering the front door should be wearing a mask.
During an interview on 1/19/21 at 11:00 A.M., CMT B said:
-The staff has had education on COVID.
-The staff has had education on what PPE should be worn.
-The staff has had education on when to wear PPE.
-The staff should wear a mask at all times as soon as they enter the door from the outside.
-The mask should cover the nose and mouth.
During an interview on 1/19/21 at 11:10 A.M., the ADON said:
-The staff has had training on when to wear masks.
-The mask should cover the mouth and nose.
-The staff were expected to wear a surgical mask whenever they are in the building.
-The staff were expected to have their mask on as soon as they enter the front door.
-The staff were expected to have a mask on before they came to the receptionist's desk to be screened.
-There were extra masks at the receptionist's desk.
-The facility had plenty of PPE.
-There were COVID positive residents in the facility that week.
-There were residents who were quarantined (who had been out of the facility, being observed for COVID) in the facility that week.
During an interview on 1/19/21 at 11:15 A.M., the Social Service Assistant (SSA) said:
-Staff should be wearing a mask as soon as they enter through the front door.
-All staff has had COVID training.
-All staff has had PPE training.
-The facility can give staff a mask if needed.
-The facility had plenty of PPE.
MO00171423
Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines; failed to ensure infection control procedures to prevent cross-contamination during wound care by failing to ensure proper handwashing and glove changes, failed to ensure wound care supplies were placed on a barrier during wound care and when staff threw contaminated linens on the floor then picked up the contaminated linens with bare hands and exited the room with them for one resident (Resident #13); failed to ensure the facility COVID (a new disease caused by a novel (new) coronavirus) quarantine isolation unit had proper signage and Personal Protective Equipment (PPE - equipment worn to minimize exposure to a variety of hazards. Examples of PPE include such items as gloves, face masks or face shields, respirators, foot and eye protection, and gowns) supplies including mask and hand hygiene supplies, prior to entry of the quarantine unit; failed to ensure facility staff wore the proper facemask and PPE while assigned to the quarantine unit and on the non-COVID units, and failed to ensure the staff were wearing masks that covered their nose and mouth while working in the facility out of 19 sampled residents. Facility census was 62 residents with a licensed capacity for 120 residents.
1. Record review of the facility's Water Management Program for Prevention of Legionella Growth, last revised on 7/19/19, and provided by the Administrator showed a 4-page document that did not include the following requirements:
-A facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard.
-A completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
-A schematic or diagram of the facility's water system.
-A facility-specific infection prevention program or plan to deal with outbreaks of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other waterborne pathogens.
-A program and flowchart that identifies and indicates specific potential risk areas of growth within the building.
-Assessments of each individual potential risk level.
-Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility.
-Facility-specific interventions or action plans for when control limits are not met.
-Documentation of any site log book being maintained with any cleanings, sanitizing, descalings, and inspections mentioned.
Record review on 1/14/21 showed no documentation by the facility of assessment or monitoring of the facility's water management program to prevent Legionella growth.
Observations during the facility Life Safety Code room inspection with the Interim Maintenance Director (IMD) on 1/13/21 at 11:14 A.M., showed the following:
-There was stagnant brown water in a hopper in the Soiled Utility room on the northwest hall with an unknown film growing on the surface.
-The IMD acknowledged the condition and noted its location.
During an interview on 1/14/21 at 9:14 A.M., the Administrator said the following:
-The facility did have a waterborne pathogen prevention program.
-It was probably located somewhere, but where was not immediately known.
-He/She would just print off a copy for review.
-He/She was not able to provide any documentation of the facility assessment or monitoring of the facility's water management program to prevent Legionella growth.
4. During the entrance conference interview on 1/11/21 at 9:26 A.M., the Administrator said:
-The facility currently had two COVID positive residents on the red zone unit which would be going off isolation that day, due to the end of the resident's 14 day quarantine/isolation for COVID .
-The two residents had tested positive for COVID on 12/30/20 and the last day for both resident's quarantine/isolation was 1/11/21.
-The yellow zone was for new admits and suspected cases for 14 day observation.
-They had six new resident admissions on the yellow unit who were on 14 day monitoring.
-He/She had enough PPE supplies, and they receive weekly shipments from their corporate office and have had no problems at that time with PPE supplies.
During observation and interview 1/11/21 at 9:14 A.M., of the facility entrance to the COVID quarantine-isolation unit showed:
-There was a hallway across from the nursing station that was blocked off by a plastic barrier with a zipper down the center of the plastic that served as the entrance to the COVID quarantine-isolation unit.
-The plastic wall barrier did not show any signage identifying that this area was an isolation unit or a COVID unit, and there was no stop sign on the plastic barrier or anywhere around the area, that gave instruction to staff as to what they should do prior to entering (see the nurse, apply personal protective equipment, etc.) or that they should not enter at all.
-Certified Medication Technician (CMT) C said, the isolation/quarantine units were divided into two zones, the red zone (isolation area) and yellow zone(quarantine area).
--CMT C said the quarantine-isolation unit ran from the yellow zone side which started at room [ROOM NUMBER] and ended onto the red zone side, COVID unit side, with the last room [ROOM NUMBER].
--The red zone COVID unit started at the end of the hallway by room [ROOM NUMBER].
-CMT C said the COVID unit entrance was through the red zone plastic barrier zipper wall and was for staff and visitors to enter through to get to the red zone and the yellow zone.
-Staff were to exit off the quarantine-isolation units through the yellow zone zipper plastic wall barrier. That barrier wall started at room [ROOM NUMBER] which was located on the side of the nursing station.
-CMT C said the red zone which was the COVID unit, was the main entrance that the staff was to enter through.
-CMT C said, the facility had a total of six residents on the units and had one dedicated CNA staff member on each unit.
-He/She said CMT's and nursing staff float onto the units to provide medication and treatments.
-They put on full PPE when giving medication and treatments.
Observation on 1/11/21 at 12:57 P.M., of the facility PPE supplies with the environmental services director showed:
-The facility split the PPE supplies between the medical records and nursing central supplies area.
-Both areas had sufficient amount of PPE supplies for the size of the facility.
Observation on 1/13/21 at 9:30 A.M., of the facility COVID units showed:
-The facility had no isolation signage posted on the outside of entrance of the plastic barrier wall or upon entrance to the yellow unit, indicating the type of isolation precaution for that unit and what PPE was required prior to entering of the unit.
-The yellow zone unit had four new admission or readmission residents on 14 day isolation
-The observation of the yellow zone unit showed the facility did not have any N95 or KN95 masks in the three isolation carts that were located on the yellow zone unit.
-There was one staff, CNA C, on the yellow zone unit.
-CNA C was assigned for one-one staffing with a resident at risk for behaviors on the yellow unit.
-CNA C had a surgical mask on while in the resident room providing personal care and had a face-shield in place.
-Signage on the resident's door for required PPE showed to perform hand hygiene, use isolation gown, KN95 mask, face shield, goggles or both, and gloves.
-The sign on the resident's door showed Stop! Droplet precautions. Door must remain closed at all times.
-Upon exiting off the yellow zone isolation unit and into the PPE doffing/donning area, the facility did not have any N95 or KN95 masks stocked in the isolation carts and had no hand sanitizer to use prior to exiting the yellow units area.
During an observation and interview on 1/14/21 at 8:35 A.M., of the yellow zone quarantine unit showed:
-The facility had no isolation signage posted on the outside of the entrance barrier wall or at the entrance of the yellow unit, indicating the type of isolation precaution for that unit and what PPE was required prior to entering the unit.
-Beyond the red zone unit, through another plastic barrier wall, was a clean space between the red and yellow zone. The area had no PPE supplies except a box of gloves on the hand rail.
-The yellow zone quarantine isolation unit had four new admission residents.
-CNA C was sitting in the doorway of room [ROOM NUMBER] with no facemask in place. He/She did not have a surgical mask, N95 or KN95 mask on while sitting on the unit upon arrival to the unit.
-CNA C's surgical mask was laying on the bedside table in front of him/her.
-CNA C said that facility staff were required to have full PPE on when they entered a resident room, and then CNA C placed a surgical mask on his/her face.
-He/She said staff should wear a N95 mask while on the unit, but for the last four days he/she had asked the facility nursing staff for mask supplies and had not received any N95 masks, and was only able to get the surgical mask.
-Observation of the yellow unit isolation carts showed no N95 or KN95 masks in the carts.
-CNA C was the only staff assigned to the yellow zone unit, but he/she was assigned for one on one staffing with a resident.
-CNA C said when other resident's on the yellow unit required care, the other CNA staff come to provide those care.
During an interview on 1/14/21 at 9:11 A.M., the ADON said:
-The facility had plenty of KN95 and N95 masks and the COVID units were supplied by the central supplies/medical records person.
-He/She was not aware staff did not have KN95 and/or N95 masks on the unit.
During an observation and interview on 1/15/21 at 12:20 P.M., of the yellow zone unit showed:
-The facility had no isolation signage posted on the outside of entrance barrier wall or at the entrance of the yellow unit, indicating the type of isolation precaution for that unit and what PPE was required prior to entering the unit.
-The yellow unit had a census of three residents.
-CNA B was in the hallway passing meal trays with a surgical mask in place and assisted the resident with meal setup.
-He/She was not wearing a N95 or KN95 mask.
-At 12:23 P.M., CMT D entered the yellow unit with a black cloth mask on.
-CMT D went into isolation room [ROOM NUMBER] with a cloth mask in place and without a gown, face-shield or gloves.
-CMT D administered medication to the isolated resident and then exited the room, sanitized his/her hands and left the yellow unit.
-CNA B said that they were required to have full PPE on when entering the resident room for COVID positive residents.
-He/She was told all he/she needed for PPE on the yellow zone unit was a surgical mask and gloves for the care of the resident.
-Observation of isolation signage on the resident's door for required PPE and showed to perform hand hygiene, use isolation gown, KN95 mask, face shield, goggles or both, and gloves when they enter the resident rooms.
-The sign on the resident's door showed Stop! Droplet precautions. Door must remain closed at all times.
-He/She was not aware of the isolation signage on each resident's doors.
-He/She was providing one on one staffing with a resident.
-CNA B said he/she had observed other staff, including the CMT's and charge nurses, enter the residents' rooms not wearing full PPE.
-He/She said was not aware if there were any N95 masks on the yellow zone unit and he/she was not aware he/she had to wear a N95 mask.
-They have face shields and goggles on the isolation carts if staff need them.
-Observation of the isolation carts showed no N95 or KN95 masks in the carts.
During an observation and interview on 1/15/21 at 12:30 P.M., with CMT D showed:
-The CMT D had a black cloth mask on while at the medication cart in the non- isolation unit area.
-He/She was told by a charge nurse staff he/she only needed to wear a cloth mask or surgical mask to enter the yellow zone unit.
-If a resident was on isolation, he/she would expect to wear full PPE to enter the unit or when caring for the residents.
-The yellow zone unit was for new admits and a step down unit and was told by the charge nurse that he/she did not need full PPE to enter the unit.
During interview 1/15/21 at 12:35 P.M., RN B and RN C said:
-The yellow unit had three residents on isolation at that time and one resident was placed on one to one staffing.
-The residents remain on quarantine for 14 days.
-Facility staff should be required to wear full PPE when the enter the resident's room (i.e. surgical mask with face-shield, gown and gloves) on the yellow zone isolation unit.
-RN B said he/she was informed by administrative staff a few days ago, he/she was not required to wear a N95 mask, only a surgical mask while on the yellow unit.
-They would expect all staff to wear a surgical mask at all times when on the yellow zone unit.
During interview 1/15/21 at 12:40 P.M., the ADON and Social Service Assistant (SSA)/resource staff person said:
-They were not aware the yellow zone isolation unit did not have N95 masks.
-Facility staff had not reported to them any shortage of supplies on the unit.
-He/She would expect the yellow isolation unit to be stocked with the required supplies needed, including N95 masks and hand sanitizer.
-The type of PPE required on the yellow zone unit would be a surgical mask for use when in the hallway and full PPE, including wearing a N95 mask, when staff enter the resident's room.
-At the entrance of the yellow zone unit they would expect a stock of gowns, N95 masks, gloves, and hand sanitizer to use prior to entering the units.
-Medical records/central supplies staff member were responsible for ensuring to stock the isolation carts each day. The facility staff would report missing PPE items to administration or a central supplies person.
-Would have expected administration or the person setting up the barrier would be responsible for ensuring to have isolation signage at the entrance of the yellow zone unit.
-Staff should have been able to sanitize hands prior to donning PPE.
-The facility had recent trainings in December related to the COVID-19 units and the type of PPE to use for green, yellow and red zones.
-The facility does not have a shortage of N95 or KN95.
2. Record review of the facility's Hand Hygiene/Handwashing policy, dated 11/28/12 and revised on 1/10/18, showed:
-Hand hygiene was defined as cleaning hands by using either handwashing with soap and water, antiseptic hand wash, or antiseptic hand rub such as an alcohol-based hand sanitizer.
-Examples of when to perform hand hygiene included:
--Before and after having direct contact with a patient's intact skin.
--After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings.
--If hands will be moving from a contaminated body site to a clean body site during resident care.
--After removing gloves.
Record review of the facility's Glove Use - Nursing policy, dated 11/28/12 and revised on 1/31/18, showed:
-Gloves used for contact should be removed and discarded after contact with each person, fluid item, or surface.
-Hand hygiene should be performed after removing gloves. When hands are not visibly dirty, alcohol-based sanitizers were the preferred method for cleaning hands. Soap and water were the preferred method for cleaning visibly dirty hands.
Record review of the facility's policy, dated 3/5/20, Infection Control - Interim policy addressing the healthcare crisis related to Human Corona virus, said:
-All facility employees in all departments will be required to wear a surgical mask during their shift (universal masking) following the extended use guidelines as follows:
-The facemask should be removed and discarded if soiled, damaged or hard to breathe through.
-Healthcare Professionals must take care not to touch their facemask.
-If they touch or adjust their facemask they must immediately perform hand hygiene.
Review of the Center for Disease Control and prevention (CDC) https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations, updated 12/14/20, showed:
-CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed SARS-CoV-2 infection. Facilities should develop policies and procedures to ensure recommendations are appropriately applied in their setting.
-Ensure signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (e.g., outside of a resident's room, wing, or facility-wide).
-Health care provider (HCP) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
--When available, facemasks are preferred over cloth face masks for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others.
--Cloth masks should NOT be worn instead of a respirator or facemask if more than source control is needed.
--To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth mask.
--HCP should remove their respirator or facemask, perform hand hygiene, and put on their cloth mask when leaving the facility at the end of their shift.
-HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID) infection should adhere to Standard Precautions and use a NIOSH-approved N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection.
Review of the facility COVID-19 policy, revised 12/15/20, showed:
-Hand-sanitizer should be available at the front entrance and throughout high traffic areas.
-When possible, the building will designate a unit, hallway, floor or cluster of rooms dedicated to caring for known or suspected COVID-19 residents. It was preferred, but not always possible to have a physical barrier between zones.
-The yellow zone were for residents that:
--Had symptoms that were pending test or who had symptoms but had a negative COVID-19 test.
--Monitor new admissions or readmission for the 14 days quarantine period or may designate a cluster of rooms for new admissions and readmission if space allowed.
-The facility was to ensure residents on the yellow zone unit under observation were isolated and cared for using all recommended COVID-19 Personal Protective Equipment (PPE, is specialized clothing or equipment worn by an employee for protection against infectious materials) including gloves, N95 respirator mask (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or KN95 (personal protective equipment that protect against airborne particles and liquids) face-mask, and eye protection.
-Surgical facemasks were to be worn by all staff during their shift.
-Change all PPE including N95 mask and sanitize face-shield or goggles when moving between red zones to yellow or green zones.
-All recommended COVID-19 PPE should be worn during care of residents under 14 day quarantine observation, which included use of eye protection (i.e. goggle or disposable face shields that cover the front and sides of the face) N95 mask, gloves, and gown.
-Hand hygiene should be performed by facility staff before putting on and after removing PPE, including gloves.
-The facility should ensure that hand hygiene supplies were readily available to all staff in every care location.
-For Droplet precaution: in addition to gloves and gowns, staff should don (apply) a N95 or KN95 mask and eye protection within six feet of the resident.
3. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses:
-Sepsis (infection) due to Methicillin Susceptible Staphylococcus Aureus (a bacteria).
-Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Peripheral vascular disease (inadequate blood flow to the extremities).
-Non-pressure chronic ulcer (open wound) of the lower leg.
Record review of the resident's care plan, dated 6/26/20, did not identify the resident having skin impairment.
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 10/26/20, showed the resident:
-Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15.
-Did not have any skin impairment.
-Required extensive staff assistance with bed mobility, transfers, and bathing.
-Required limited staff assistance with personal hygiene.
Record review of the resident's January 2021 Physician's Order Sheet (POS) showed:
-Triple Antibiotic Ointment (Neomycin-Bacitracin-Polymyxin - an antibiotic ointment) apply to coccyx (tailbone) topically every 24 hours as needed for prophylaxis (prevention), may keep at bedside, dated 12/16/20.
-Wound care: left buttocks wound, cleanse with soap and water, apply all purpose ointment (Bacitracin, Nystatin, A&D and Zinc) twice daily and every six hours as needed, dated 12/9/20.
-Outside wound care provider to evaluate and treat as needed, dated 12/9/20.
-Nystatin Powder (a medication used to treat yeasty skin) 100,000 unit per gram (gm), apply per directions topically every day shift for rash, dated 10/31/20.
-Cleanse abdominal wound with wound cleanse, pat dry, apply calcium alginate (a wound treatment) with dressing one time a day for prophylaxis for abdominal wound, dated 10/2/20.
-Nystatin Cream 100,000 unit per gm apply to buttocks, genitalia, and pannus (under the abdominal folds) topically four times a day for incontinence, pain, rash, dated 9/20/20.
During an interview on 1/12/21 at 10:15 A.M., the resident said
-He/She had a wound on his/her left buttock and he/she was raw on the right side of his/her genitalia.
-He/She described his/her wounds as red and raw like a diaper rash.
-He/She kept two urine graduates on his/her bedside table which he/she preferred to keep uncovered so he/she could access it easily when he/she needed to use them.
Observation of the resident's room on 1/15/21 at 9:15 A.M.,. showed two urine graduates with urine on his/her bedside table.
Observation on 1/15/21 at 10:15 A.M., of Registered Nurse (RN) E providing wound care for the resident showed:
-The two urine graduates had been emptied of urine and were on the bedside table uncovered.
-RN E entered the resident's room, and without washing or sanitizing his/her hands, removed two strips of dry weave moisture wicking dressing (a dressing used to help keep areas that have skin to skin contact dry to treat or prevent yeast growth) from a package on the sink and placed them on the resident's bedside table next to the urine graduates that still contained small amounts of urine in the bottoms of each without a barrier.
-Without washing or sanitizing his/her hands, RN E put on clean gloves, then opened the resident's door and left the resident's room to get warm water from the utility room for the wash basin with his/her gloves on and opened the utility room door with the same gloves.
-With the same gloves, RN E opened the resident's door, entered the resident's room, placed the wash basin on the resident's bedside table next to the same urine graduates without a barrier and placed wash cloths in the wash basin.
-With the same gloves, RN E removed a wash cloth from the wash basin and cleaned the skin under the resident's left abdominal folds, threw the wash cloths on the floor, picked up a clean, dry towel, patted dry the resident's left abdominal fold, then threw the towel on the floor.
-With the same gloves, RN E applied Nystatin powder, smoothed the powder on the resident's skin, then, with the same gloves, picked up one of the strips of dry weave moisture wicking dressing and placed it under the resident's left abdominal fold.
-With the same gloves, RN E assisted the resident to turn in the bed, removed wash cloths from the wash basin, cleaned under the resident's right abdominal folds, threw the wash cloths on the floor, picked up a clean, dry towel, patted dry the resident's right abdominal fold, then threw the towel on the floor.
-With the same gloves, RN E applied Nystatin powder, smoothed the powder on the resident's skin, removed the second strip of dry weave moisture wicking dressing, and placed it under the resident's right abdominal fold.
-With the same gloves, RN E adjusted his/her glasses on his/her face, removed another strip of dry weave moisture wicking dressing from the package, and placed it under the center section of the resident's abdominal fold, then with the same gloves, adjusted his/her facemask.
-RN E removed his/her gloves and without washing or sanitizing his/her hands, opened the resident's door, exited the resident's room, went to the clean utility room and returned to the resident's room with additional wash cloths.
-Without washing or sanitizing his/her hands, RN E put on clean gloves, and cleaned the resident's buttocks with wash cloths from the wash basin then threw the wash cloths on the floor with the rest of the dirty linens.
-With the same gloves, RN E picked up a clean, dry towel, patted dry the resident's buttocks and under the right buttock fold, and threw the towel on the floor.
-With the same gloves, RN E picked up the tube of barrier cream and applied the cream to the resident's right buttock, left buttock and under the resident's right buttock fold.
-RN E removed his/her gloves, and without washing or sanitizing his/her hands, he/she began touching and moving the resident's personal items on his/her chair in his/her room and adjusting his/her glasses and facemask.
-Without washing his/her hands, RN E touched the resident's door knob, exited the resident's room, went to the clean utility room, then returned to the resident's room with a pad for the resident's bed.
-Without washing his/her hands, RN E put on clean gloves, removed the dirty bed pad from under the resident, placed the clean pad under the resident, touched the resident to assist him/her to turn in bed, then finished adjusting the bed pad under the resident.
-With the same gloves, RN E picked up the tube of ammonium lactate cream (a skin protectant cream) and applied cream to the resident's right leg and foot.
-With the same gloves, RN E picked up the tube of ammonium lactate cream and applied cream to the resident's left leg and foot, adjusted his/her face mask, and continued to apply cream to the resident's left leg and foot.
-RN E removed his/her gloves, and without washing or sanitizing his/her hands, adjusted his/her facemask and glasses, then with ungloved hands, picked up the dirty linens from the floor, touched the door knob, exited the room, opened the door to the dirty utility room, disposed of the dirty linens and exited the dirty utility room without washing or sanitizing his/her hands.
During a follow up interview on 1/15/21 at 12:17 P.M., RN E said:
-He/She should have put any supplies for wound care, including the dry weave moisture wicking dressing on a barrier and not on the bedside table next to the resident's urine graduates.
-He/She should have washed his/her hands upon entering the resident's room, after removing gloves, and before exiting the resident's room.
-He/She should have changed his/her gloves after completing cares on one body part before going to the next.
-He/She should not have left the resident's room with gloves on.
-He/She should not have touched the resident or the resident's environment with contaminated gloves.
-He/She should not have touched h
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "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: Federal abuse finding, 6 life-threatening violation(s), Special Focus Facility, $135,621 in fines, Payment denial on record. Review inspection reports carefully.
- • 100 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $135,621 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Parkview Healthcare's CMS Rating?
CMS assigns PARKVIEW HEALTHCARE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Parkview Healthcare Staffed?
CMS rates PARKVIEW HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 46%, compared to the Missouri average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Parkview Healthcare?
State health inspectors documented 100 deficiencies at PARKVIEW HEALTHCARE during 2021 to 2025. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 93 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Parkview Healthcare?
PARKVIEW HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 103 residents (about 86% occupancy), it is a mid-sized facility located in KANSAS CITY, Missouri.
How Does Parkview Healthcare Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, PARKVIEW HEALTHCARE's overall rating (1 stars) is below the state average of 2.5, staff turnover (46%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Parkview Healthcare?
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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Parkview Healthcare Safe?
Based on CMS inspection data, PARKVIEW HEALTHCARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Parkview Healthcare Stick Around?
PARKVIEW HEALTHCARE has a staff turnover rate of 46%, which is about average for Missouri nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Parkview Healthcare Ever Fined?
PARKVIEW HEALTHCARE has been fined $135,621 across 7 penalty actions. This is 3.9x the Missouri average of $34,435. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Parkview Healthcare on Any Federal Watch List?
PARKVIEW HEALTHCARE is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.