LAWSON MANOR & REHAB
For profit - Corporation
60 Beds
CIRCLE B ENTERPRISES
Data: November 2025
Trust Grade
0/100
#407 of 479 in MO
Photo by Anthony Garrett
Photo by Anthony Garrett
Photo by Anthony Garrett
1 / 5 photos
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Lawson Manor & Rehab has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #407 out of 479 nursing homes in Missouri, placing them in the bottom half of facilities in the state, and #2 out of 2 in Ray County, meaning there is only one local alternative that is better. Although the facility has shown improvement over time, decreasing from 34 issues in 2024 to just 2 in 2025, the staffing situation is troubling with a turnover rate of 75%, which is significantly higher than the state average. Additionally, the facility has reported serious incidents, including cases of physical abuse where one resident was choked and another was pushed, resulting in injuries, which raises concerns about resident safety. While the facility does maintain average RN coverage, the overall poor ratings and troubling incidents suggest that families should carefully consider their options before choosing this home.
- Trust Score
- F
- In Missouri
- #407/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 75% turnover. Very high, 27 points above average. Constant new faces learning your loved one's needs.
- Penalties ○ Average
- $13,000 in fines. Higher than 60% of Missouri facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 63 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 16%
Review needed
34 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 34 issues
2025: 2 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: 75%
29pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $13,000
Below median ($33,413)
Minor penalties assessed
Chain: CIRCLE B ENTERPRISES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (75%)
27 points above Missouri average of 48%
The Ugly 63 deficiencies on record
3 actual harm
Aug 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect Resident#1's right to be free from abuse when...
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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 protect Resident#1's right to be free from abuse when he/she was choked around the neck by another resident (Resident #2) causing redness to Resident #1's neck and Resident #1 feared Resident #2. Facility census was 48.Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, showed:-Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment resource allocation to support the following objectives: -Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and/or any other individual; -Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents, neglect of residents, theft/exploitation/misappropriation of resident property; -Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities. Review of the facility's Resident Rights policy, dated February 2021, showed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' rights to be free from abuse, neglect, misappropriation of property and exploitation. 1.Review of Resident # 1's electronic medical record showed:-The resident was admitted to the facility on [DATE];-Diagnoses included: Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in life), anemia (the blood doesn't have enough health red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen through the body), dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), and chronic kidney disease (a longstanding disease of the kidneys, leading to kidney failure). Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 7/20/2025, showed:-He/She had adequate hearing, clear speech, understands others and makes self understood;-He/She scored nine on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents). This score indicated moderately impaired cognition.Review of the resident's comprehensive care plan, dated 8/18/25, showed: -Interventions related to physical aggression;-He/She had the potential to be physically aggressive to his/her spouse due to diagnoses of dementia, anxiety and depression;-He/She has received physical aggression from his/her spouse, who has been observed with his/her hands around Resident #1's neck;-Staff are to administer medications as ordered and monitor/document behaviors every shift;-Resident #1 was to only have supervised visits with his/her spouse for safety;-Rooming situation is to be re-evaluated as needed. Review of Resident #1's August 2025 progress notes showed the following:-8/3/2025 at 10:00 P.M.: Resident #1 was observed in his/her room laying on the bed. Resident #2 was observed standing over Resident #1 with his/her hands around Resident #1's neck. The residents were separated. After assessment, redness and tenderness were present around Resident #1's neck. He/she rated the pain of 3/10 and refused pain medication; -8/4/2025 at 1:34 P.M.: The administrator conducted an interview with Resident #1 regarding the incident involving Resident #2. Resident #1 stated he/she did not clearly recall the incident. When asked if he/she felt safe sharing a room, Resident #1 responded he/she did feel safe and wishes to share a room. Resident #1 denied any pain or discomfort and stated he/she felt safe at the facility. The administrator spoke with Resident #1's legal guardian, who expressed that if both residents felt safe, the guardian would prefer the residents continue to share a room, noting recent life transitions have already been difficult for them and further separation may lead to increased emotional distress. Resident #1 verbalized relief and happiness upon learning the resident would be allowed to return to the shared room; -8/15/2025 at 1:11PM: Resident #1 was interviewed following an incident involving Resident #2 on 8/15/2025. Resident #1 denied fear of Resident #2 and expressed the desire to continue residing in their shared room. Resident #1 was informed that, for safety, Resident #2 was relocated to a different room at this time. The resident was assessed and found to have no injuries. 2.Review of Resident #2's electronic medical record showed:-He/She was admitted to the facility on [DATE];-Diagnoses included: anemia, type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease, dementia, and anxiety disorder.Review of the resident's admission MDS, dated [DATE], showed:-He/She had adequate hearing, clear speech, understands others and make self understood;-He/She scored 10 on the BIMs. This score indicates moderately impaired cognition. Review of the resident's comprehensive care plan, dated 8/18/2025, showed: -Interventions related to impaired cognition related to dementia; -Staff were to administer medications as ordered and monitor for behaviors each shift;-Staff were to keep the resident's routine as consistent as possible;- Staff were two engage the resident in simple, structured activities that avoid overly demanding tasks. Review of Resident #2's August 2025 progress notes showed the following:-8/3/2025 at 10:00 P.M.: The nurse was called to the secure unit due to staff observing Resident #2 standing over Resident #1, with his/her hands around Resident #1's neck, shaking him/her. Staff redirected Resident #2. Resident #2 stated he/she was frustrated and could not stop what he/she did. Resident #2 could not explain why he/she was frustrated but did state he/she was sorry and would not do it again. Resident #2 stated he/she wanted the beverage Resident #1 had and it was taking too long. The physician was notified and gave orders for a medication change for Resident #2. Resident #2's legal guardian was notified and stated they support the residents continuing to share a room, provided both residents continue to feel safe. -8/4/2025 1:56 P.M.: The administrator completed an interview with Resident #2 regarding an incident that occurred with Resident #1. Resident #2 could not recall the incident. When prompted to describe what he/she could remember, Resident #2 stated that he/she believed he/she and Resident #1 had an argument, but could not recall the nature or cause of the argument. When informed that he/she was observed with his/her hands around Resident #1's neck, Resident #2 appeared visibly surprised and responded he/she didn't know why he/she would have done that. Resident #2 stated he/she feels safe and wants to continue to share a room with Resident #1; -8/15/2025 11:00 A.M.: At approximately 4:00 A.M., staff heard screaming from Resident #1 and #2's room. Upon entering, staff observed Resident #2 standing at the foot of Resident #1's bed. When asked what occurred, Resident #1 stated he/she had been asleep when Resident #2 attempted to choke Resident #1, removed Resident #1's call light to prevent him/her for calling for help, and tried to pull him/her off the bed by the legs. Resident #2 was immediately relocated to another room. While being removed from the room, Resident #2 told Resident #1 that he/she is going to get it when Resident #2 gets home. The physician and guardian were notified of the incident. The guardian requested Resident #2 be transferred to inpatient psychiatric care for further evaluation and management; -8/15/2025 7:01 P.M.: Resident #2 returned from the local hospital with no new orders and a suggestion to follow up with his/her primary care provider. 3. During an interview on 8/18/2025 at 2:50 P.M., Licensed Practical Nurse (LPN) A said:-LPN A worked the night shift 8/14/25 into 8/15/25;-At approximately 4:00 A.M., the staff on the locked unit called LPN A to the unit. Staff stated that they heard a scream from Resident #1 and #2's room. When they entered the room, Resident #2 was observed standing at the foot of Resident #1's bed. LPN A assisted staff in separating the residents and relocated Resident #2 to a different room for safety. Resident #2 told LPN A this did not concern the staff and to go away;-LPN A then assessed Resident #1 and asked him/her what happened. Resident #1 told LPN A that Resident #2 first took the call light away so Resident #1 could not call for help. Then Resident #2 put his/her hands around Resident #1's neck and choked him/her. Resident #2 then attempted to pull Resident #1 from the bed by pulling on his/her left foot. After the assessment, it was noted Resident #1 had redness around the neck, but no other noted injuries. During the assessment, Resident #1 told LPN A he/she feared Resident #2; -He/She notified the Administrator and Director of Nursing (DON). The DON notified the residents' legal guardian and physician. Law enforcement and Emergency Medical Services (EMS) were called and arrived at the facility. EMS assessed Resident #1 and found no injuries, and the resident was not taken to the hospital. Law enforcement took statements from all staff involved. Resident #2 was placed on one-to-one supervision when out of his/her room;-LPN A had received no instruction or guidance as to Resident #2's behaviors or need for monitoring when starting his/her shift on 8/14/2025. Review of the statement from Certified Nurses Assistant (CNA) A provided to law enforcement on 8/15/25 showed:-CNA A heard screaming at 3:45 A.M. coming from Resident #1 and #2's room. CNA A ran into the room and found Resident #2 at the end of Resident #1's bed. When asked what happened, Resident #1 stated Resident #2 grabbed his/her left ankle and told Resident #1 to shut up. Resident #1 stated that Resident #2 choked him/her, and CNA A observed a red mark on Resident #1's neck. Resident #1 also stated that Resident #2 took the call light away from him/her;-CNA A assisted Resident #2 to a different room and then completed a statement. During an interview on 8/18/25 at 1:59 P.M., LPN B said:-He/She was not working at the time of either incident involving Resident #2. LPN B received instructions from the nurse on the previous shift that Resident #2 is on one-to-one supervision when out of his/her room; -Earlier the morning of 8/18/25, LPN B was walking down the hall of the locked unit. He/she looked into Resident #2's room and did not see him/her in the room. LPN B then looked into Resident #1's room. Resident #1 was sitting in the room, eating breakfast. Resident #2 was standing in the room near the door to the bathroom. LPN B escorted Resident #2 from the room to the dining room. The staff members on the locked unit were assisting other residents in cleaning up after breakfast;-LPN B assessed Resident #1. Resident #1 stated he/she was doing well and continued eating his/her breakfast. During an interview on 8/18/25 at 3:11 P.M., the DON said:-Resident #2 was on one-to-one supervision when out of his/her room. This means the staff monitor for when the resident leaves his/her room. When out of the room, staff should be within reach of the resident;-The DON expected staff to notify the charge nurse if they need to step away to assist a resident who required two staff assistance so the charge nurse can come monitor the resident who is on one-to-one supervision. During an interview on 8/18/25 at 3:11 P.M., the Administrator said:-When a resident was on one-to-one supervision, staff was to be within arm's reach of the resident, or what is safest for the staff and resident; -The Administrator expected staff to notify the charge nurse if they need to step away to assist a resident who requires two staff assistance so the charge nurse can come monitor the resident who is on one-to-one supervision. Observation of Resident #1 on 8/18/25 at 1:51 P.M., Resident #1 was noted to be laying in his/her bed, awake. During an interview, Resident #1 said he/she is doing well and feels safe at the facility. He/she has no concerns but would like to share a room with Resident #2 again. Observation of Resident #2 on 8/18/25 at 1:57 P.M., Resident #2 was noted to sitting in the dining room, watching other residents during an activity. During an interview, Resident #2 said he/she is doing well and feels safe at the facility. He/she has no concerns. Intake 2590597
Jul 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed protect one sampled resident's (Resident #1) right to be free from physical abuse when Resident #2 grabbed Resident #1 by his/her arms and pus...
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Based on interview and record review, the facility failed protect one sampled resident's (Resident #1) right to be free from physical abuse when Resident #2 grabbed Resident #1 by his/her arms and pushed him/her backwards causing Resident #1 to fall and sustain a skin tear approximately 3 inches in length to the underside of the resident's left arm. The facility census was 44.On 7/30/25, the Administrator was notified of the past noncompliance which began on 7/23/2025. The facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 7/28/25. Review of the facility's Abuse Policy, revised April 2021.,showed: -The residents have the right to be free from abuse. -The facility's abuse, policy consists of a facility-wide commitment and resource allocation to support protecting residents from abuse, from other residents, staff, or any individual. -The facility will develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. - Ensure adequate staffing and oversight. -Provide staff orientation and training programs to include abuse prevention and the management of verbally or physically aggressive resident behaviors.1.Review of Resident #1's admission face sheet., showed: The resident resided on secured memory care unit. Diagnoses included: Alzheimer's dementia, history of spinal fractures, and weakness.Review of Resident #2's admission face Sheet showed the resident was a new admission as of 7/3/25 with a diagnoses of severe dementia, and delusional disorders. The resident was under guardianship, and resided on the secured memory unit. Observation of the resident on 7/30/25 at 2:25 P.M., showed resident lying in bed, awake with significant confusion, not alert to surroundings or self. Left underside of forearm showed a healing skin tear approximately 3 inches in length. Resident was unable to explain how it happened.Review of Resident #1's Nursing Progress notes., showed that on 7/23/25 around 2:14 P.M. resident was found sitting on the floor in the hallway with legs out in front of him/her. Resident #1 sustained a skin tear when resident #2 pushed resident backwards out of his/her room. Resident #2 admitted to removing the resident out of his/her room. Resident #1's skin tear was treated with triple antibiotic ointment and a Band-Aid, family and physician had been notified.Review of the facility's abuse investigation report dated 7/28/25, showed the abuse of the resident occurred on 7/23/25, the report does not have a time indicated as to when it happened. The resident was identified as independent with ambulation and had been ambulating on 7/23/25 on the hallway of the secured unit. The resident entered into Resident #2's room, and Resident #2 placed his/her hands on Resident #1 and guided the resident backwards out of the room's doorway causing Resident #1 to fall and sustained a skin tear to left arm. Resident #2 reported that Resident #1 should not have been in his/her room. Resident #1 was treated for the skin tear and Resident #2 was placed on 1:1 monitoring (one staff person is assigned to monitor the resident continually). No witnesses were indicated on the facility investigation report. A Velcro stop sign was placed on Resident #2's door to detour Resident #1 from entering Resident #2's room again.During an interview on 7/30/25 at 11:30 A.M., CNA-A said on 7/23/25 he/she heard resident #2 yelling down the hall, and saw resident #1 on the floor. Resident #1 had a new skin tear to the left arm. CNA-A called for the nurse. Resident #2 was cussing and yelling and punching his fists and shaking them at people. CNA A said resident #2 had a short fuse and can become agitated and aggressive easily. Resident #2 was placed on 1:1 monitoring on 7/23/25 after resident #1 was picked up off the floor. CNA A reported that Resident #2 had to be sent out to the hospital earlier in the month for hitting, kicking at staff, and threatening others on the unit. CNA A stated he/she had not received any training on how to de-escalate resident #2's behaviors.Observation on 7/30/25 at 1:11 P.M., showed the resident up and independent with ambulation on the secured memory unit walking closely next to others on the hall. He/she was alert, with extreme confusion, and an unsteady gait. Velcro stop sign hanging off the door frame and not up to detour confused resident's on the memory care unit from wondering into the resident #2's room.Review of resident's nursing progress note records showed that on 7/3/25 day of admission resident was verbally abusive towards others, using foul language and exit seeking. Then, 2 days later on 7/5/25 at 10:32 A.M., the resident was verbally abusive, screaming at staff, slamming doors continually, and frightening other residents. Local law enforcement was called and arrived at the facility around 10:40 A.M., resident begun hitting, kicking, and punching at law enforcement. The resident was removed from the facility in hand cuffs and taken to local ER (Emergency Room) for a mental health evaluation. On 7/6/25 the resident was returned to the secured unit at the facility with new order for prescription Seroquel (an anti-psychotic used to treat behaviors). On 7/13/25 nursing notes showed that the resident was agitated, belligerent, verbally abusive and refusing medications. On 7/23/25 at 2:19 P.M. Nursing notes showed charge nurse was informed that resident had pushed another resident out of his/her room, causing resident #1 to fall on the ground. Resident #2 told nursing staff he/she had pushed resident #1 and that resident #1 fell. Resident #2 was escorted to his/her room and 1:1 monitoring initiated. Police contacted and came to the facility. Guardian and physician notified. DON (Director of Nursing) and the Administrator notified. Review of resident #2's care plan, dated 7/21/25 showed the resident required the memory care unit for dementia care and elopement risks. On 7/24/25 the day after Resident #1 was pushed down, the care plan was updated to show that resident could become physically aggressive towards others and interventions included placing resident on 1:1 monitoring and to guide the resident away from the source of the distress and if resident's response is aggressive, staff are to walk away and re-approach later. The care plan did not address interventions for the staff to take with the resident when the resident physically assaults others. The care plan was not updated with interventions when witnessed behaviors initially began on 7/5/25.Review of resident's physician ordered behavior monitoring was initiated on 7/21/25 and showed the resident's behavior monitoring record was not completed accurately on 7/23/25 when the resident pushed another resident down. The staff documented that the resident had no behaviors that day. On 7/24/25 the behavior record indicated no behavior, however the nurses notes indicated the resident did have behaviors that day. On 7/27/25 the behavior monitoring documentation was omitted.During an interview 7/30/25 at 10:58 A.M., CMT A said Resident #2 was unpredictable and had witnessed violent behaviors with the resident starting on 7/5/25 with hitting, punching and throwing things over anything that might upset him/her. CMT A said he/she had no training on how to manage behaviors like that while working on the secured unit. CMT A worries about the safety of other residents because of this resident's history since admission to the facility. On 7/23/25 CMT A observed resident #1 requiring assistance off the floor outside of resident #2's room, and the nurse was taking care of resident #1's skin tear of the arm. Observed resident #2 saying he/she wanted resident #1 out of his/her room. The resident was placed on 1 on 1 monitoring after the event.During an interview on 7/30/25 at 11:40 A.M., CNA B said Resident #2 becomes easily agitated at other residents. CNA B heard resident #2 yelling went to investigate and saw Resident #1 sitting on the floor outside of Resident#2's room in the hallway. Resident #1 had a skin tear and nurse cared for the skin tear. Resident #2 was placed on 1 on 1 monitoring with a stop sign hooked to the door to hopefully stop other residents from going into Resident #2's room.During an interview on 7/30/25 at 1:15 P.M. the Administrator and the Regional Director of Operations said the facility failed to assess, identify, and care plan for behavioral risk, resulting in physical harm to another resident. Immediate actions were being implemented to include staff training and monitoring ongoing for 90 days and through Quality Assurance (QAPI) oversight.Intake 2570182
Dec 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Refer to Event ID NI0V12.
Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was...
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Refer to Event ID NI0V12.
Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46.
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 F0728
(Tag F0728)
Could have caused harm · This affected multiple residents
Refer to Event ID NI0V12.
Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of...
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Refer to Event ID NI0V12.
Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census was 46.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Refer to Event ID NI0V12.
Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculos...
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Refer to Event ID NI0V12.
Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for six sampled newly hired employees. The facility census was 46.
Oct 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one resident's visitation rights were not restricted when Resident #6 had a visitor that was asked to leave and not pe...
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Based on observation, interview, and record review, the facility failed to ensure one resident's visitation rights were not restricted when Resident #6 had a visitor that was asked to leave and not permitted to visit the resident. This affected one of six sampled residents (Resident #6). The facility census was 47.
Review of facility policy, Resident Rights, undated, showed:
-Resident has right to receive visitors of their choosing at time of their choosing and interact and participate with members of community and activities inside and outside facility, subject to resident's right to deny visitation, and in a manner that did not impose on rights of another resident.
-Facility must provide immediate access, subject to resident's right to deny or withdraw consent at any time to any resident by:
-Immediate family and other relatives of resident;
-Facility must have written policies and procedures regarding visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction, and must inform each resident of right to receive visitors whom they designate and their right to withdraw or deny such consent any time.
Review of facility policy, visiting hours, undated, showed:
-Resident has right to receive visitors of his or her choosing at the time of his or her choosing, subject to resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident.
-The facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences.
-The facility will provide immediate access to any resident subject to the resident's rights to deny or withdraw consent at any time.
-The facility will have immediate access to the resident by any of the following:
-Others who are visiting with the consent of resident;
-Visiting hours will be posted to encourage reasonable restrictions.
1. Review of Resident #6's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/14/24, showed:
-He/She was cognitively intact;
-He/She had clear speech and was able to make self-understood and understand others;
-It was very important to have family or close friends involved in discussions about his/her care;
-He/She was independent with mobility, personal hygiene, dressing, and eating;
-Diagnoses included: anxiety (feeling of fear, dread, or uneasiness that could be normal reaction to stress), depression (mental condition that involved persistent feelings of sadness and loss of interest in activities), manic depression (serious mood disorder that can affect how person feels, thinks, or acts), diabetes ( a condition resulting in too much sugar in the blood), and bipolar disorder (a mental illness that can cause extreme mood swings, along with changes in energy, activity levels, and concentration).
Review of physician's orders, dated 10/23/24, showed:
-Activities as tolerated or desired;
Review of care plan, undated, showed:
-Resident had an activity of daily living self-care performance deficit due to limited mobility;
-Encourage resident to participate to fullest extent possible with each interaction.
During an interview on 10/23/24 at 8:51 A.M., Resident said:
-His/Her friend, Visitor A, came to see him/her;
-The Business Office Manager (BOM) would not let his/her friend come to see him/her;
-It upset him/her that his/her friend could not come and visit them;
-He/She was his/her own person and did not have a guardian;
-The visitor who was denied access had been former employee of facility;
-He/She had a friendship with the individual and wanted to be allowed his/her right to have visits.
During an interview on 10/23/24 at 9:19 A.M., BOM said:
-He/She had never denied visits to anyone;
-If an employee was terminated from the facility they were not allowed back into the building;
-He/She was not aware of any former employees that had been at the facility to visit a resident that he/she had turned away;
-There was no visiting hours at facility, people could visit at time of choosing;
-He/She was not aware of turning any visitors that came to facility to see Resident #6.
During an interview on 10/23/24 at 10:25 A.M., Director of Nursing (DON) said:
-Facility did not have set visiting hours;
-He/She was aware of one former employee that had came to facility after hours, the former Assistant Director of Nursing (ADON), and he/she had been escorted out of facility due to making staff uncomfortable and exhibiting disturbing behaviors.
During an interview on 10/23/24 at 10:42 A.M., Licensed Practical Nurse (LPN) A said:
-He/She was aware of one resident, Resident #6, who had been denied a visit from visitor A by the BOM;
-The BOM told Visitor A that he/she could not come into the facility;
-Visitor A was a former employee;
-He/She observed Visitor A being denied access on two visit attempts;
-Resident #6 was his/her own person and able to make his/her own decisions.
During an interview on 10/23/24 at 11:20 A.M., ADON said:
-He/She was not aware of any residents being denied visits;
-Former employees were allowed to come back into facility to visit residents.
During an interview on 10/23/24 at 11:38 A.M., Visitor A said:
-He/She had previously worked at the facility;
-He/She voluntarily quit and left the faciity on good terms;
-He/She attempted to visit Resident #6 on 9/1/24, 9/4/24, and 9/9/24;
-On his/her first attempt on 9/1/24 he/she was in facility applying for a position, after he/she completed the application he/she went down the hallway to visit the resident;
-The BOM came out of his/her office and yelled at him/her saying he/she was not allowed to go down the hallway;
-When he/she returned for an interview, he/she inquired with the Administrator if he/she could visit the resident and the Administrator said he/she was not allowed to be there;
-During a third attempt to visit the resident, the Administrator again said he/she was not allowed;
-He/She had been Certified Nurse Aide in the facility a long time and quit working at the facility at end of November 2023.
During an interview on 10/23/24 at 12:09 P.M., DON said:
-Resident #6 was his/her own responsible party;
During an interview on 10/23/24 at 11:45 A.M., Administrator said:
-He/She had never turned resident's visitors away from facility;
-He/She had not turned away the former staff member;
-Visitors were allowed to visit the facility at any time;
-He/She did not turn away Visitor A;
-Visitor A had been terminated and was on the facility do not rehire list;
-He/She expected residents with capacity and were their own person to be allowed to have access to visitors of their own choosing.
MO243891
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
Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl ...
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Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46.
Review of facility policy, Abuse Investigation and Reporting, Revised July 2017, showed:
-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, shall be thoroughly investigated by facility management.
-Individual conducting the investigation will as a minimum:
-Review the completed documentation forms;
-Review the resident's medical record to determine events leading up to the incident;
-Interview the person(s) reporting the incident;
-Interview any witnesses to the incident;
-Interview the resident (as medically appropriate);
-Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition;
-Interview staff members (on all shifts) who have had contact with the resident during the period of alleged incident;
-Interview the resident's roommate, family members, and visitors;
-Interview other residents to whom the accused employee provides care or services; and
-Review all events leading up to the alleged incident.
1. Review of Resident #1's, Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/30/24, showed:
-Cognition is severly impaired;
-He/She was dependent for upper and lower body dressing, mobility, and personal care;
-He/She had been on a scheduled pain medication regimen;
-He/She made vocal complaints of pain within the assessment reference date (The look back period for the assessment).
-He/She was taking high-risk drugs including an opioid (a broad group of pain-relieving medicines that work with brain cells);
-Diagnoses included: Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and ability to perform everyday tasks), cognitive communication deficit (a difficulty communicating effectively due to underlying cognitive impairment), reduced mobility, malaise (a general feeling of discomfort, illness, or lack of well-being)
Review of care plan, undated, showed:
-He/She had potential for pain
-Administer pain medication as ordered;
-Turn and repposition according to turn schedule;
-Observe for factors that increase/decrease my pain;
-Observe for intolerable pain;
-Measure my pain level using pain scale 1 to 10;
-Coordinate with my physician to manage my pain medication for optimum control of my pain;
-Coordinate care with hospice to maintain comfort;
-Observe for non-verbal signs of pain ie. facial expressions, pulling away, fighting;
Review of physician's orders, dated 12/4/24, showed:
-Initial order started 10/14/24, Check fentanyl patch every shift, to ensure fentanyl patch is intact;
-Fentanyl transdermal patch dosage increased on 11/15/24, to 50 MCG/HR (Fentanyl), apply 1 patch transdermal every 72 hours for pain.
-Current physician orders as of 12/4/24 show fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain,
Review of controlled medication sheets for Resident #1's fentanyl patch showed:
-Page 53: Fentanyl 25 mcg, 1 patch every 72 hours, balance forwarded was 2
-On 11/6/24, at 4:00 A.M., 1 dose was given, balance was 1 patch;
-On 11/11/24 at 12:48 A.M, nothing entered as given, balance was 0;
-On 11/19/24 entry showed count corrected, balance was 1 patch;
-On 11/19/24, entry showed at 8:00 A.M. fentanyl was administered, and balance was 0.
-On Page #54: Fentanyl 50 mcg, apply 1 patch every 72 hours showed:
-On 11/7/24, at 8:00 P.M., 2 patches were received from the pharmacy;
-On 11/8/24, at 8:30 A.M., 1 patch was given, balance remaining was 1 patch
-On 11/18 an entry was made with a line through it that showed balance was 0 patches, but no administration time was entered;
-On Page #55, fentanyl 50 mcg, change every 72 hours showed:
-On 11/11/24, balance was 5 patches;
-On 11/12/24, 1 dose was given, no time of administration entered, and balance was 4 patches;
-On 11/13/24 at 6:49 A.M., 1 patch was administered, balance remaining was 3 patches;
-On 11/15/24 at 10:30 A.M., 1 patch was administered, balance remaining was 2 patches;
-On 11/18/24 at 1:00 P.M., 1 patch was administered, balance remaining was 1 patch;
-On 11/21/24 at 9:27 A.M., 1 patch was administered, balance remaining was 0 patches.
-On Page #60, fentanyl 50 mcg, apply one patch topically, showed page was started 11/18/24;
-On 11/18/24, balance received from pharmacy was 5 patches;
-On 11/24/24 at 8:00 A.M., 1 patch was administered, balance remaining was 4 patches;
-On 11/27/24 at 8:00 A.M., 1 patch was administered, balance remaining was 3 patches;
-On 11/30/24 at 8:00 A.M., 1 patch was administered, balance remaining was 2 patches;
-On 12/3/24 at 9:30 A.M., 1 patch was administered, balance remaining was 1 patch;
-On 12/3/24 at 9:30 A.M., 1 patch was administered, balance remaining was 0 patches, and a note written by DON showed stuck to op-site/tegaderm (sticky bandage that holds patches in place) had to replace patch.
Review of Medication Administration Record, dated 11/1/24 to 12/4/24, showed:
-Unknown start date, Fentanyl transdermal patch 72 hour 25 mcg/hr (fentanyl), apply 1 patch transdermal one time a day every 3 days for pain, discontinued on 11/7/24 at 3:50 P.M.
-Administered 11/5/24 by LPN C;
-Unknown start date, fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain, apply 1 50 mcg/hr patch topically and change every 72 hours and remove per schedule, discontinued on 11/15/24 at 8:35 A.M;
-Administered 11/8/24 at 9:01 A.M. by LPN D;
-Administered 11/11/24 at 11:49 A.M. by Assistant Director of Nursing (ADON);
-Administered 11/14/24 at 7:37 by LPN A;
-Unknown start date, fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain, apply one -50 mcg/hr patch topically and change every 72 hours and remove per schedule;
-Administered 11/15/24 at 8:38 A.M. by LPN D;
-Administered 11/18/24 at 1:00 P.M., by LPN A
-Administered 11/21/24 at 9:50 A.M., by LPN A;
-Administered 11/24/24 at 5:40 P.M. by LPN D;
-Administered 11/27/24 at 8:12 by Registered Nurse (RN) A;
-Administered 11/30/24 at 9:58 A.M. by LPN D
-Administered 12/3/24 at 9:26 A.M. by DON.
Review of progress notes, dated 11/4/24 to 12/5/24, showed:
-On 11/6/24, LPN C wrote resident complained of pain, nurse applied fentanyl patch at 4:00 A.M;
-On 11/7/24, New order entered showed fentanyl transdermal patch 72 hour 50 mcg/HR (fentanyl) controlled drug, apply 1 patch transdermal every 72 hours for pain, apply one 50 mcg/hr patch topically and change every 72 hours and remove per schedule;
-On 11/8/24, LPN D wrote fentanyl 50 mcg patch placed on during morning to upper left back;
-On 11/11/24, LPN B wrote resident fentanyl patch not present on residents back as was reported to this nurse, new patch applied this morning, secured with op-site to right scapula. DON notified.
-On 11/15/24 at 8:21 P.M., LPN B wrote resident was jerking arms and legs spontaneously
During an interview on 12/4/24 at 9:10 A.M., Licensed Practical Nurse (LPN) A said:
-He/She went to check for Fentanyl patch on resident #1 on 11/13/24 and could not find the patch;
-He/She got Certified Medication Technician (CMT) A to go look for patch with him/her and CMT could not locate the patch;
-He/She looked in blankets and found the adhesive dressing cover to the patch but could not locate the patch;
-He/She also checked trash in room and could not locate fentanyl patch;
-The patch had last been applied on 11/12/24;
-He/She notified the Director of Nursing that the patch was missing on 11/13/24;
During an interview on 12/4/24 at 11:02 A.M., Director of Nursing (DON) said:
-He/She was made aware by LPN A of Resident #1's fentanyl patch was missing on 11/13/24;
-He/She found transdermal cover to patch but the patch was not located;
-The bed had already been stripped, and he/she assumed it may have ended up in laundry;
-He/She did not do an investigation but guessed she probably should have completed one;
-He/She just spoke with hospice nurse and LPN A verbally to investigate the missing patch;
-He/She did not document anything in regards to his/her verbal investigation;
-After fentanyl patch was found missing on 11/13/24, LPN A started placing patch lower and out of resident's reach;
-He/She did not recall Resident #1's patch to be missing on any other dates;
-He/She did not recall LPN B calling him/her on 11/11/24 regarding Resident #1 having fentanyl patch missing.
During an interview on 12/4/24 at 11:29 A.M., Nurse Aide A said:
-He/She provided cares to Resident #1;
-He/She had not seen Resident #1 without his/her pain patch while providing cares;
-He/She had been told by an overnight employee but was not sure which employee that Resident #1's fentanyl patch was missing and had been seen on his/her night stand and to notify nurse if the fentanyl patch had been found;
-In last few weeks Resident #1 had episode of jerking really bad and appeared as if he/she was experiencing pain.
During an interview on 12/4/24 at 12:48 P.M., Nurse Aide B said:
-He/She was aware of Resident #1's fentanyl pain patch cover being found on resident's bed side table but could not remember the specific date.
During an interview on 12/4/24 at 1:18 P.M., Corporate Consultant said:
-He/She expected a full investigation to be completed when the fentanyl patch was found missing;
-He/She expected statements to be gathered, physician to be notified;
-He/She found that his/her facility staff did not do anything in regards to an investigation;
-He/She was not made aware of the missing fentanyl patches until he/she arrived on-site to facility today.
During an interview on 12/4/24 at 2:40 P.M., LPN A said:
-He/She discovered at 10:45 A.M. today that Resident #1 did not have his/her pain patch on;
-He/She went and got the DON to report;
-The DON reported that he/she had placed the fentanyl patch on the resident on12/3/24 because he/she was working as the charge nurse;
-He/She did not have an additional fentanyl patch to replace missing patch today so had to call in a new order;
-The DON told him/her that he/she had to waste a fentanyl patch on 12/2/24 because he/she had placed the fentanyl patch on Resident #1 backwards;
-He/She did not notify the physician of the missing patch today or on 11/13/24;
-He/She had to administer as needed pain medication due to not having another patch.
During an interview on 12/4/24 at 3:04 P.M., Administrator said:
-He/She expected an investigation to be completed when a fentanyl patch was found to be missing off a resident;
-He/She would have expected the investigation to be documented;
-The DON had not informed him/her about the missing fentanyl patch on 11/11 or 11/13;
-He/She had not been made aware of the missing fentanyl patch until today;
-He/She would have expected the physician to be notified.
During an interview on 12/4/24 at 3:35 P.M., DON said:
-He/She became aware of missing fentanyl patch this morning by LPN A;
-He/She was not able to locate patch;
-He/She discovered resident's bed had been stripped;
-He/She did check laundry but was not able to locate the missing fentanyl patch;
-He/She contacted the physician's group who referred him/her to hospice about the missing patch;
-He/She spoke with hospice and looking at a different narcotic for resident due to the ongoing missing fentanyl patches.
MO245460
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 F0728
(Tag F0728)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census...
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Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census was 46.
The facility did not provide an NA certification policy.
Review of the NA employee list showed:
-NA A employed since 6/24/24;
-NA B employed since 4/26/24;
-NA C employed since 7/15/24;
-NA D employed since 7/16/24;
-NA E employed since 6/7/24;
-NA F employed since 2/12/24.
During an interview on 12/4/24 at 11:29 A.M., NA A said:
-He/She was not enrolled in any Certified Nurse Aide class;
-He/She had worked in facility since July 2024, and worked in facility last year from July 2023-November 2023.
During an interview on 12/4/24 at 12:48 P.M., NA B said:
-He/She was not enrolled in CNA class after working for the facility for six months;
-He/She was told several times that he/she would be put in the next CNA class but has never been enrolled in any class.
During an interview on 12/4/24 at 1:40 P.M., NA F said:
-He/She had worked in the facility for 10 months and had not been enrolled in CNA class;
During an interview on 12/4/24 at 2:40 P.M., Licensed Practical Nurse (LPN) A said:
-He/She was concerned that facility had a limited number of CNAs, and that he/she was often left with only NA's who could work.
During an interview on 12/4/24 at 3:04 P.M., Administrator said:
-He/She expected the Director of Nursing (DON) to ensure competency of facility nurse aides;
-Certified Nurse Assistance training was being offered at their sister facility;
-NA A, NA B, NA C, NA D, NA E, NA F had not been enrolled in class, but would be scheduled to start CNA class in January 2025.
During an interview on 12/4/24 at 3:30 P.M., DON said:
-He/She was responsible for nurse aide competencies;
-Facility had an operational change and had not gotten nurse aides enrolled in class;
-He/She had nurse aides scheduled to be enrolled in next class being offered at sister facility in January.
MO245460
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable dis...
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Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for six sampled newly hired employees. The facility census was 46.
Review of facility policy, employee screening for tuberculosis, revised March 2021, showed:
-All employees are screened for latent tuberculosis infection and active TB disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment.
-Newly hired employee is screened for LTBI and active TB disease after an employment offer had been made but prior to employee's duty assignment.
Observation on 12/4/24 at 1:00 P.M. showed Director of Nursing (DON) could not locate requested employee sample of TB tests for the following employees:
-Dietary Aide A, date of hire 10/17/24;
-Certified Nurse Aide (CNA) A, date of hire 10/16/24;
-Nurse Aide (NA) G, date of hire 10/11/24;
-NA H, date of hire 10/24/24;
-NA I, date of hire 11/6/24;
-Certified Medication Technician (CMT) A, date of hire 11/17/24.
During an interview on 12/4/24 at 1:20 P.M., Director of Nursing (DON) said:
-He/She could not locate TB tests of sampled employees including Dietary Aide A, CNA A, NA G, NA H, NA I, and CMT A;
-TB testing should be completed upon hire;
-The TB testing process fell a part when he/she stopped doing the hiring;
-He/She did not follow up to ensure TB testing was being completed on all new hires.
During an interview on 12/4/24 at 3:04 P.M., Administrator said:
-He/She expected TB testing to be completed before employee starts employment;
-He/She expected documentation of the TB testing to be maintained by the facility.
MO245460
Mar 2024
27 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on interviews the facility staff failed to ensure residents had timely access to their personal funds after business hours and on the weekend. This affected one of 12 sampled resident's. Residen...
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Based on interviews the facility staff failed to ensure residents had timely access to their personal funds after business hours and on the weekend. This affected one of 12 sampled resident's. Resident #11, was not able to access personal funds after hours. The facility census was 40.
The facility did not provide policy on funds access.
Review of facility policy, Resident Rights, revised February 2021, showed:
-Access personal records pertaining to him or herself.
-Manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes).
1. Review of Resident #11's Quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 13, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact.
-He/She had clear speech, was able to make self understood and understand others;
-He/She used walker and wheelchair for mobility;
-He/She required set up or clean up assistance with eating, oral hygiene, toileting, bathing, upper and lower body dressing, putting and taking off footwear, rolling left to right, sitting to lying, lying to sitting, sitting to standing, and with chair to bed, toilet, and tub transfers.
-Diagnoses included generalized muscle weakness, tremor (a condition causing involuntary shaking or movement), difficulty in walking, and frailty (an age-related physical debility including weakness and fatigue and reduced tolerance for medical and surgical interventions).
Review of care plan, undated, showed:
-Resident will remain in least restrictive environment;
-Resident enjoys getting out of facility;
During an interview on 3/12/24 at 9:55 A.M., the Resident said:
-He/She cannot get money from personal funds on the weekend.
-If He/She needed knew he/she needed money for weekend he/she would have to get it on Friday.
During an interview on 3/14/24 at 3:08 P.M., the Business Office Manager said resident do not have access to money on weekends or after hours.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said residents currently do not have access to their personal funds after hours or on weekends.
CONCERN
(D)
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 observations, interviews and record review, the facility failed to ensure staff provided adequate pain control for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff provided adequate pain control for one of 12 sampled residents (Resident #192). The facility census was 40.
Review of facility policy, administering pain medications, showed:
-Pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care pan, and the resident's choice related to pain management.
-Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals.
-Pain management is a multidisciplinary care process that includes the following:
-assessing the potential for pain;
-Recognizing the presence of pain;
-Identifying the characteristics of pain;
-Addressing the underlying causes of the pain;
-Developing and implementing approaches to pain management;
-Identifying and using specific strategies for different levels and sources of pain;
-Monitoring for the effectiveness of interventions; and
-Modifying approaches as necessary.
-Acute pain should be assessed every thirty to sixty minutes after the onset and reassessed as indicated until relief is obtained
-Administer pain medications as ordered.
-Re-evaluate the resident's level of pain thirty to sixty minutes after administering.
1. Review of Resident #192's facility face sheet, dated 3/15/24 showed:
-He/She was admitted [DATE];
-He/She was own responsible party;
-Diagnosis included sepsis (A life threatening complication of an infection), bacteremia (a condition with the presence of viable bacteria circulating in blood), extranodal non-hodgkin's lymphoma (a cancer that starts in lymphatic system), and epilepsy (a brain disorder that causes recurring, unprovoked seizures).
Review of care plan, undated, showed:
-He/She experienced presence of frequent pain in right leg due to recent surgery;
-Evaluate pain daily using 1-10 scale;
-Resident's pain goal is 1-3;
-Administer pain medication as ordered;
-Monitor for worsening pain and report to physician.
Review of physician's orders dated 3/8/24 showed:
-Started 3/8/24 pregabalin 50mg 1 capsule by mouth three times daily for pain at 8:00 A.M., P.M., and hour of sleep;
-Started 3/8/24, Acetaminophen 500 mg, 2 tabs by mouth every 8 hours as needed for pain;
-Start 3/8/24, Oxycodone/APAP 10/325 every 6 hrs for pain as needed;
-Start 3/11/24, Pain assessment every shift
Review of Medication Administration Record, dated 3/8/24 to 3/15/24, showed:
-Pregabalin 50mg administered three times daily starting 3/10/24-3/14/24;
-No administration had occurred of acetaminophen 500mg 2 tabs by mouth every 8hrs as needed for pain;
-Oxycodone - APAP 10/3/24 every 6 hrs as needed for pain
-Administered 3/8/24 at 11:00 P.M., was documented effective;
-Administered 3/9/24 at 10:00 P.M., was documented effective;
-Administered 3/10/24 at 10:00 P.M. was documented effective;
-Administered 3/11/24 at 9:30 P.M. was documented as effective;
-Administered 3/11/24 at 7:00 A.M. was documented pain at 7, improved to 3 at follow up;
-Administered 3/11/24 at 3:01 P.M. was documented pain at 6, , was resting after;
-Administered 3/12/24 at 7:36 A.M. was documented pain at 8, improved to 5 at follow up;
-Administered 3/13/24 at 8:45 A.M. was documented pain at 8, improved to 4 at follow up;
-Administered 3/13/24 at 10:15 P.M. was documented pain at 8, improved to 5 at follow up;
-Administered 3/14/24 at 6:15 A.M. was documented pain at 7, was documented as effective;
-Administered 3/14/24 at 3:30 P.M. was documented pain at 8, was documented as effective;
-Administered 3/14/24 at 9:30 P.M. was documented pain at 8, was documented improved;
-Administered 3/15/24 at 5:00 A.M. was documented pain at 8, was documented improved and resting;
-Pain assessment every shift:
-3/8/24 no assessement of pain scale documented on MAR;
-3/9/24 during 7:00 A.M. - 7:00 P.M. shift pain was an 8
-3/9/24 during 7:00 P.M. to 7:00 A.M. shift pain was 0
-3/10/24 during 7:00 A.M. to 7:00 P.M. shift pain was a 7;
-3/10/24 during 7:00 P.M. to 7:00 A.M. shift pain was a 0;
-3/11/24 during 7:00 A.M. to 7:00 P.M. shift pain was a 7;
-3/11/24 during 7:00 P.M. to 7:00 A.M. shift pain had no documentated entry;
-3/12/24 during 7:00 A.M. to 7:00 P.M. shift pain was an 8;
-3/12/24 during 7:00 P.M. to 7:00 A.M. shift pain was a 0;
-3/13/24 during 7:00 A.M. to 7:00 P.M. shift pain was a 7;
-3/13/24 during 7:00 P.M. to 7:00 A.M. shift pain was an 8;
-3/14/24 during 7:00 A.M. to 7:00 P.M. shift pain was an 8;
-3/14/24 during 7:00 P.M. to 7:00 A.M. shift pain was an 8.
Review of pain evaluation assessment, dated 3/8/24, showed total pain score of 8-13 indicating moderate pain.
Observation on 3/12/24 at 12:36 P.M. showed beautician was in beauty shop with resident and grabbed nursing staff and said his/her leg was about to fall off. MDS Coordinator said to beautician that the Director of Rehabilitation was looking for something to keep resident's leg from sliding off his/her wheelchair leg rest. Resident was observed wincing in pain by squinting eyes and grimmacing his/her mouth. Director of Rehabilitation arrived to beauty shop with a different wheelchair leg and wheeled resident to therapy department.
Observation on 3/12/24 at 12:41 P.M. showed resident continued wincing in pain as Director or Rehabilitation as therapy staff applied leg brace. Therapy staff held resident's leg as the Director of Rehabilitation attempted to apply a different wheelchair leg to resident's wheelchair. Resident's leg began shaking and resident continued to wince and grimace mouth stating ouch.
During an interview on 3/12/24 at 12:45 P.M., resident said:
-The facility did have gait belt around my leg to keep it on the wheelchair leg rest;
-He/She arrived to facility on 3/8/24;
-He/She had only been out of bed and in his/her wheelchair twice;
-When facility staff took the gait belt off that was securing leg to wheelchair leg rest, his/her leg fell off, and it was not going to stay on leg rest without gait belt;
-He/She needed pain medication;
-He/She believed he/she was scheduled to get some around 12 or 12:30 P.M. but had not received pain medication yet.
-His/Her leg stays on the current leg rest until he/she is moved and then it falls off
Observation on 3/12/24 at 12:47 P.M. showed Director of Rehabilitation arrived to therapy room with different wheel chair leg pedal. He/She believed to have found one that was longer than what the resident currently had on his/her wheelchair.
During an interview on 3/12/24 at 2:00 P.M., resident said he/she had asked for pain medication at 12:00 P.M. and he/she had not gotten it yet. He/She had just asked for it again a few minutes ago.
During an interview with resident on 3/15/24 at 4:15 P.M.
-He/She had asked for pain medication today when the doctor was in the facility at 3 P.M. and he/she has not got any pain medication yet. The nurse that was rounding with the doctor said he/she would get pain medication when he/she was done rounding;
-He/she had not received any pain medication since asking at 9am that day;
-When he/she asked for pain pill he/she would just get Tylenol;
-He/she was under impression he/she could get his/her pain medications staggared every 4-6 hours;
-The doctor told him/her he/she had to ask for his/her pain medications and he/she advised him/her that he/she had been asking but not receiving the pain medications as requested;
-Before lunch his/her whole leg fell down off the rest which caused him/her to yell out in pain;
-Nurse Aide C responded to the room when his/her leg rest fell down and staff took him/her to therapy where they adjusted his/her leg rest;
-His/Her leg fell around 10:00 A.M. right before the bingo and singing in dining room;
-He/she is hopeful his/her leg did not get messed up further;
-When his/her leg fell the pain was at a level 10;
-This morning when he/she asked for pain medication her pain level was a 7;
-On Wednesday night going into Thursday morning he/she requested pain medication at 12 A.M. when he/she was placed on bed pan and did not receive it, when the CNA came back in 1 hour and thirty minutes later to take him/her off bed pan he/she again asked for pain pill at 1:30 A.M. He/She said she asked CNA for help but felt ignored. The CNA told him/her they would tell the nurse when he/she got back from their break about his/her request for pain medication. At 7:00 A.M. he/she had still not received his/her pain medication and asked the CNA again if the nurse was back from break as he/she was still waiting on his/her pain medication;
During an interview on 3/15/24 at 4:32 P.M. Nurse Aide (NA) C said:
-The resident had notified him/her the leg rest had fallen;
-He/She asked resident if they wanted him/her to assist with getting leg rest back up and resident said yes;
-He/she notified Assistant Director of Nursing (ADON) and asked him/her to help get leg rest back in place
-The resident did ask me for pain medication around 1:40 P.M.;
-He/She thinks he/she may have told the ADON but may not have told him/her that resident requested pain medication.
During an interview on 3/15/24 at 4:34 P.M., Certified Nurse Aide (CNA) B said:
-The resident is in severe pain during transfers;
-He/She was not aware of pain other than during his/her transfers;
-He/She felt like resident was doing better since he/she first arrived to facility.
During an interview on 3/15/24 at 4:39 P.M., the ADON said:
-He/She was unsure why there was a delay on resident's medications;
-Resident did ask for medications while he/she completed rounds with the physician;
-He/She did not get to her;
-Resident requested medications around 3:30 P.M.;
-He/She asked patient what she wanted and resident said he/she wanted his/her pain medication and did not want tylenol;
-Facility did pain assessments each shift;
-He/She would not expect resident to have to wait from 7:30 A.M. to 1:00 P.M. to receive pain medication;
-He/She would pull medication from emergency kit if there was not pain medicaiton in facility;
-Resident told him/her this morning his/her leg had fallen;
-He/She assisted NA B with readjusting residents leg after it had fallen;
-He/She administered Tylenol at 9:00 A.M. that morning.
During an interview on 3/15/24 at 4:50 P.M., Director of Rehabilitation said:
-Resident's knee was to be immobilied;
-Resident's hip range of motion would not have been affected if his/her leg rest fell as immobilizer was on and would have kept knee immobilized;
-Resident had told him/her he/she had pain in his/her hip not moving;
-Resident had not told him/her he/she had not been receiving his/her pain medication;
-The resident not receiving his/her pain medication would impact what resident would be able to do during therapy sessions;
-Resident was currently no touch weight bearing;
-Therapy was working on strengthing resident and would work with resident on transfer training but had not done because of resident's pain level;
-Therapy had ordered resident a new chair with longer seat depth and longer leg rest so resident could scoot back and leg rest would fit on end of food pedal.
During an interview on 3/15/24 at 4:55 P.M., Certified Occupational Therapy Assistant (COTA) A Said:
-The resident expressed pain with movement;
-The resident would grimace when he/she was in pain;
-The resident did say pain medication would help with his/her pain;
-He/She had suggested to resident that he/she stay on top of pain medication to help with his/her pain.
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
-Pain medication should be given to resident as soon as nurse heard about it;
-He/She would expect nurse to go down and assess resident first;
-He/She expected nurse to give pain medication within ten minutes of request from resident.
During an interview on 3/15/24 at 7:35 P.M., the Regional Director of Nursing said:
-He/She expected staff to administer pain medication within ten minutes of request.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 they cared for residents in a dignified way, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure they cared for residents in a dignified way, that any reasonable person would expect, when they failed to provide privacy by leaving window blinds open during a resident's morning care exposing the resident (Resident #8), Failed to respect privacy of a resident, when the facility posted personal information about a resident's daily care routine on wall above his/her bed for anyone to view, (Resident #20), and additionally failed to provide treat residents in a dignified manner when staff stood while feeding resident during meals (Resident #37) and when staff administered inhalers in the dining room, which affected one of 12 sampled residents, (Resident #17). The facility census was 40.
Review of facility policy, dignity, revised February 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.
-Provided with dignified dining experience.
-Signs posting a resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible (example of taped to the inside of the closet door).
-Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
3. Review of Resident #8's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/7/24, showed:
-He/She had a BIMS score of 6, showed resident had severe cognitive impairment.
-He/She had clear speech and was able to make self-understood and usually understood others;
-He/She used wheelchair for mobility;
-He/She required partial to moderate assistance for toileting, upper body dressing, personal hygiene, rolling left to right, sitting to lying transfers, toilet transfers and putting on and taking off footwear;
-He/She required set up and clean up assistance for eating, oral hygiene, lower body dressing;
-He/She required substantial/maximal assistance with bathing, sitting to standing, chair to bed transfers.
Review of care plan, undated, showed:
-He/She required assistance to complete daily activities of care safely related to dementia and impaired cognition;
-Give him/her privacy
During an observation on 3/13/24 at 5:12 A.M. Certified Nurse Aide (CNA) C and Nurse Aide (NA) B were assisting in getting resident dressed and up for the day. Resident's bed was located in room beside the window and blinds were open. Resident was observed in a hospital gown and the staff assisted resident up in her wheelchair. Once resident was up in his/her wheelchair staff assisted resident with removing his/her hospital gown and to put on a shirt. The residents chest was facing the open blinds while seated in wheelchair.
During an interview on 3/14/24 at 9:47 A.M., CNA D said:
-During morning routine of getting resident out of bed he/she would knock, go in the room, wash hands, put on gloves on, and get ready cleaned up;
-He/She should have ensured the resident was covered by pulling the curtain, closing the blinds in the room, and not exposing residents as that was a resident's dignity and he/she worked in resident's home.
During an interview on 3/14/24 at 10:15 A.M., CNA B said he/she should have ensured privacy of residents by pulling resident's curtain, shutting resident's door, and ensuring the blinds were closed.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said he/she expected staff to provide privacy when providing cares including closing curtain and shutting blinds.
4. Review of Resident #20's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/12/24, showed:
-He/She had a BIMS score of 11, showed resident had mild cognitive impairment.
-He/She used wheelchair for mobility;
-He/She required set up or clean up assistance with eating, oral hygiene
-He/She required partial/moderate assistance with toileting, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene,
-Diagnoses included disk degeneration of lumbosacral region, mild mental retardation (a condition resulting in an IQ score of 60-69), bipolar disease (a disorder associated with mood swings ranging from depressive lows and manic highs), epilepsy (a brain disorder that causes recurring, unprovoked seizures)
Review of Resident #20's quarterly MDS, dated [DATE], showed:
-He/She had no BIMS score completed;
-He/She required substantial/maximal assistance for eating, oral hygiene, upper body dressing,
-He/She was dependent for toileting, bathing, lower body dressing, putting on and taking off footwear, rolling left and right, sitting to lying, sit to stand, chair to bed transfers, and dependent for wheelchair transport.
-Diagnoses included mild mental retardation (a condition resulting in an IQ score of 60-69), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), osteoarthritis of knee, contracture, cognitive communication deficit, and epilepsy
Review of care plan, undated, showed:
-Resident will remain in least restrictive environment;
-Resident was dependent on two staff for bed mobility, transfers, toileting, and bathing;
-Resident is transferred by using a mechanical lift, 2 staff present;
-Resident uses a wheelchair for all mobility and needs one person total assist with mobility;
-Resident is at risk for pressure ulcers, skin tears, bruises, and other skin breakdown. He had a past history of pressure injuries and is incontinent of bowel and bladder. He/She is essentially non-ambulatory, and spends a lot of time in a broad chair;
-Resident needed pillows or other supportive/protective devices to assist with positioning;
-Discontinue orders to float heals dated 3/2/21;
Observation on 3/13/24 at 6:37 AM showed a sign hanging above resident's head of bed, that read, please make sure resident wears boots at all times while in bed and up in chair as it helps prevent wounds.
5. Review of Resident #37's quarterly MDS, dated [DATE], showed:
-He/She had a BIMS score of 99, Resident did not participate or was unable to answer so cognitive status was undetermined.
-He/She used a wheelchair mobility;
-He/She was independent with eating;
-He/She required partial to moderate assistance with toileting, bathing, upper body dressing, rolling left to right, sitting to lying, lying to sitting on aside of bed.
-He/She required substantial assistance with lower body dressing, personal hygiene, putting on and taking off footwear, and moving from sitting to standing, chair to bed transfers, toilet transfers, and tub transfers.
-Diagnoses included Alzheimer disease with late onset (a progressive disease that destroys memory and other important mental functions), cancer, high blood pressure, dementia (condition characterized by impairment of at least two brain functions, such as memory loss and judgement), subluxation of right hip (a condition where the ball joint had shifted partially out of socket but was not all the way out), and displaced fracture of base of neck of right femur (a condition where the bone was moved out of its original position).
Review of care plan, undated showed,
-Encourage him/her to eat;
-Provide him/her with set up assistance as needed by opening packages, cutting food, seasoning food, and identifying food;
-Allow him/her enough time to eat;
-Evaluate my eating area in dining room with appropriate table mates;
Observation on 3/12/24 at 12:05 P.M., showed LPN A was standing to feed Resident #37 who was sitting in his/her broda chair with an over the bed table in front of him/her in dining room.
Observation on 3/14/24 at 8:12 AM, showed Business Office Manager (BOM) standing to feed the resident who was positioned along window wall in dining room with an over the bed table sitting in his/her broda chair.
Observation showed on 3/14/24 at 8:18 A.M. that BOM continued to stand to feed the resident.
Observation showed on 3/14/24 08:33 A.M. that BOM continued to stand over the resident to assist with giving final bites and then removed plate from resident upon completion.
During an interview on 3/15/24 at 8:40 A.M., the BOM said:
-He/She started May of last year as the business office manager;
-He/She was not a certified nurses aide;
-He/She had not had training or instructive classes on how to assist a resident to eat;
-He/She did not know if he/she should stand to assist a resident to eat.
During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said:
-Staff should not stand to assist a resident to eat;
-Staff should be sitting and engaging with resident while assisting with meals.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said:
-Staff should sit down when assisting residents to eat;
-Staff assisting to feed residents should have training on how to assist residents to eat.
-Residents should not be assisting other residents to feed another resident.
-Resident's personal information should be inside a closet door where nobody else would see it;
6. Review of Resident #17's admission MDS, dated [DATE] showed:
- Cognitive skills severely impaired;
- Independent with eating, orally hygiene, personal hygiene and dressing the upper extremity;
- Supervision or touching assistance for transfers;
- Diagnoses included chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), and anemia (a condition in which the blood does not have enough healthy red blood cells).
Review of the resident's physician order sheet (POS), dated March 2024, showed:
- Start date: 2/1/24 - Spiriva 18 micrograms (mcg.), one cap inhaled daily using two puffs for COPD;
- Start date: 2/1/24 - Advair Diskus (Fluticasone propionate and Salmeterol) 250-50 mcg. powder, inhale twice daily for COPD. Rinse mouth after use.
Observation on 3/13/24 at 8:08 A.M., showed:
- Certified Medication Technician (CMT) A entered the dining room where the resident sat with two other tablemates and other residents in the dining room;
- CMT A did not give the resident any instructions and handed him/her the Flonase inhaler and the resident inhaled once. The resident did not rinse his/her mouth afterwards;
CMT A did not give the resident any instructions, then handed the resident the Spiriva inhaler and he/she took two inhalations.
During an interview on 3/14/24 at 1:41 P.M., CMT A said he/she should not have administered the inhalers in the dining room.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said the staff should not administer inhalers in the dining room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide acceptable accommodation of needs for two (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide acceptable accommodation of needs for two (Resident #23 and #192) of 12 residents sampled when they did not provide Resident #23 access to toileting options in his/her room and when Resident #192's leg was secured to the leg rest of his/her wheel chair with a gait belt to keep it immobilized when the foot pedal was not long enough. The facility census was 40.
Review of facility policy, accommodation of needs, dated March 2021, showed:
-Facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being.
-Resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.
-Adaptations will be made to the physical environment, including the resident's bedroom and bathroom, as well as common areas in the facility.
1. Review of Resident #23's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/23/24, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 14, he/she was cognitively intact;
-He/She had clear speech, made self-understood, and had clear comprehension of others;
-He/She was dependent on a manual wheelchair for mobility;
-He/She required set up or clean up assistance with toileting, bathing, oral hygiene, and eating;
-He/She required partial to moderate assistance with upper and lower body dressing, and all mobility.
-Diagnoses included: stroke (paralysis to one side of the body), a diabetes (a condition where there is too much sugar in the blood), cerebral palsy (a congenital disorder affecting movement, muscle tone, or posture), and dementia (a condition characterized by impairment of at least two brain functions such as memory loss and judgement)
Review of care plan, undated, showed:
-Resident required assistance from staff with grooming and personal hygiene due to weakness;
-Resident was frequently incontinent of urine;
-Assist resident to bathroom or commode as needed;
-Resident required staff assistance with mobility;
-Resident required two person extensive assistance with bed mobility;
-Resident is unable to transfer independently;
-Resident will use sit to stand for transfers;
-Resident required two staff assist with sit to stand and gait belt for transfers;
-Resident required assistance for toileting;
-Resident required assistance of two for transfers to toilet.
-Resident was at risk for urine retention due to benign prostatic hyperplasica (an enlarged prostrate which can pinch the urethra which may cause the bladder to weaken and resident may lose ability to empty bladder completely).
Observation on 3/14/24 at 9:38 A.M. showed resident was upset in hallway and had raised his/her voice and said this was the third time he/she has had to wait to go to the bathroom and something needed to change. Resident sat outside of the shower room for 25 minutes due to it being occupied by hospice staff providing another resident a bath. Resident observed telling administrator he/she was upset and something needed to change as the staff told him he needed to wait to go to the bathroom.
Observation 3/14/24 at 9:53 A.M. the Administrator asked Certified Nurses Aide (CNA) D to help the resident to the bathroom. Resident told CNA D he/she needed to use the sit and stand lift to help him/her to the toilet.
During an interview on 3/14/24 at 2:56 P.M. the resident said:
-He/She had to sit out and wait twenty-five minutes that morning to go to bathroom and staff told them they had to give someone else a shower first;
-He/She had to wait extensive time periods to use restroom twice before;
-The sit and stand lift does not fit in the restroom in his/his room.
During an interview on 3/15/24 at 4:37 P.M., Certified Nurse Aide (CNA) B said:
-Resident used restroom in the shower room because the sit to stand lift will not fit in the bathroom in the resident's room.
-The resident used the shower room every time he/she had to use the restroom;
-He/She was not aware if resident had accidents due to having to wait to use restroom in shower room.
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
-Resident cannot get in restroom in his/her room;
-He/She had to use restroom in shower room as therapy wanted him using sit to stand lift;
-The sit to stand lift would not fit through resident's bathroom door.
2. Review of Resident #192's facility face sheet, dated 3/15/24 showed:
-He/She was admitted [DATE];
-He/She was own responsible party;
-Diagnosis included sepsis (A life threatening complication of an infection), bacteremia (a condition with the presence of viable bacteria circulating in blood), extranodal non-hodgkin's lymphoma (a cancer that starts in lymphatic system), and epilepsy (a brain disorder that causes recurring, unprovoked seizures).
Review of base line care plan, dated 3/8/24, showed:
-Resident has a right leg immobilize;
-Turn with assistance of two staff;
-Resident was able to communicate;
-Resident was alert.
Review of undated care plan, showed:
-He/She had potential for falls due to pain medication, recent surgery, impaired mobility, and muscle weakness;
-Encourage to use hand rails and appropriate assuasive devices;
-Assist with ambulation, toileting, and mobility,
-Observe me for additional assuasive devices/positioning devices as needed;
-He/she was experiencing the presence of frequent pain in right leg due to recent surgery;
-Assist with change of positions slowly;
-He/She was unable to transfer independently at this time due to recent surgery in right leg;
-He/She required two person extensive assistance with all transfers;
-Utilize a mechanical lift for all transfers;
-He/She required staff assistance with mobility such as propelling wheelchair long distance.
Review of physician's orders, dated 3/8/24, showed:
-Physical therapy to complete evaluation to include four weeks of therapeutic exercise at five times per week, therapeutic activity, neuro muscular re-education, and progress to gait training as tolerated.
Observation on 3/12/24 at 12:10 P.M. showed resident was wheeled down hallway with gait belt used to secure his/her right leg to leg rest. Observation showed resident's right foot rest was elevated at 90 degree angle and the resident's foot hung over edge of right foot pedal of his/her wheelchair approximately eight inches. Licensed Practical Nurse (LPN) A told staff they could no longer use gait belt as it was considered a restraint.
During an interview on 3/12/24 at 12:10 P.M. resident said he/she had a port placed that became infected. The infection moved affected the hardware placed in his/her leg that resulted in the removal of the hardware. He/She had to have his/her leg immobilized since the recent surgery. The facility had used a gait belt on his/her leg to keep his/her leg straight and on the leg rest. He/She was currently unable to keep his/her leg on the leg rest without the gait belt as it would fall off when he/she was being moved. The facility did not have a leg rest long enough to support his/her leg.
Observation on 3/12/24 at 12:20 P.M. showed Director of Rehabilitation said to resident he/she would put a different leg rest on his/her chair to hold his/her foot.
Observation on 3/12/24 at 12:36 P.M. showed beautician told the MDS Coordinator resident's leg was about to fall off of his/her leg rest.
Observation on 3/12/24 at 12:47 P.M. in Therapy room showed Director of Rehabilitation and Certified Occupational Therapy Assistant (COTA) A applied different leg brace to resident's wheelchair and determined it was not long enough.
During an interview on 3/13/24 at 12:06 P.M., Resident said therapy put an extender on wheelchair and pillow underneath his/her leg. His/her pain was currently an 8 out of 10.
During an interview on 3/15/24 at 4:15 P.M., Resident said this morning his/her leg fell off the leg rest and he/she yelled out in pain. Nurse Aide (NA) C responded to his/her room to help her. Staff then took him/her to therapy to adjust his/her leg rest.
During an interview on 3/15/24 at 4:32 P.M., NA C said:
-Resident notified him/her of the leg rest falling and wanted assistance to get leg rest back up;
-He/She notified the Assistant Director of Nursing (ADON) to assist with getting the leg rest back up and in place.
During an interview on 3/15/24 at 4:33 P.M., CNA B said:
-Therapy told him/her on Monday to put a gait belt on resident's leg to hold his/her leg onto the leg rest.
During an interview on 3/15/24 at 4:39 P.M., ADON said:
-Resident's leg fell this morning;
-He/She assisted Nurse Aide C with putting leg back on foot rest.
-Resident told him/her they were using a gait belt on Tuesday, but he/she did not see it used;
-Facility could not use gait belt to wrap and secure leg to leg rest as gait belt should only be used around the waist;
-He/She did not observe gait belt being misused;
During an interview on 3/15/24 at 4:50 P.M., the Director of Rehabilitation said:
-He/She was told about gait belt used to secure resident's leg and decided to remedy the situation by locating a longer foot rest;
-He/She educated staff that use of a gait belt to secure leg was not appropriate;
-He/She did not know how long the gait belt had been used to secure resident's leg;
-He/She did not know of any therapy staff giving direction to staff to utilize a gait belt to immobilize leg;
-He/She did hear that resident's leg rest had fallen;
-He/She did assist staff with repositioning leg rest;
-Resident needed longer seat depth and a longer leg rest to accommodate leg.
During an interview on 3/15/24 at 4:55 P.M. the COTA A said:
-He/She was not aware of therapy directing staff to use gait belt to immobilize resident's leg;
-Therapy had to provide education to staff on positioning resident in chair to help resident stay to the back of her seat so leg would not hang off end of foot rest.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to promote self-determination for four of 12 sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to promote self-determination for four of 12 sampled residents when the facility failed to allow two sampled residents to be toileted per their request (Resident #18 & Resident #8), failed to allow resident to stay in bed per his/her request (Resident #8), failed to honor residents preferences for AM showers (Resident #11), and failed to offer meal choices. (Resident #192). This impacted four of 12 sampled residents (Resident #8, #11, #18, and #192). The facility census was 40.
Review of the facility policy, Resident Rights, revised February 2021, showed:
-Resident's have the right to self-determination
-Be supported by the facility in exercising his or her rights;
-Right to privacy and confidentiality.
Facility did not provide requested policy regarding self determination.
1. Review of Resident #18's Annual MDS, a federally mandated assessment tool completed by facility staff, dated 12/15/23, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 12, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident had moderately impaired cognition.
-He/She had clear speech;
-He/She was dependent for oral care, toileting, bathing, upper and lower body dressing, putting and taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting, and transfers;
-He/She used a wheelchair for mobility;
-He/She was always incontinent of bowel and bladder;
-Diagnoses included parkinson's disease (a condition of central nervous system that affects movement including tremors), renal insufficiency ( a condition in which the kidneys lose the ability to remove waste and balance fluids), dementia (a condition characterized by impairment of at least two brain functions, such as memory loss and judgement), difficulty in walking, and agoraphobia with panic disorder (a condition where patients avoid situations or places in where they fear being embarrassed or being unable to escape).
Review of care plan, undated, showed:
-Resident is incontinent of urine and bowel;
-Assist resident to bathroom or commode as needed;
-Assist resident with perineal cleansing as needed
Observation on 3/13/24 at 7:49 AM, showed:
-Resident asked Dietary manager if he/she could please go to the bathroom.
-Dietary manager informed administrator and regional Director of Nursing;
-Resident was wheeled out of dining room by administrator and returned thirty seconds later and did not take to restroom;
Observation on 3/13/24 at 7:54 A.M. showed: Resident said I still needed to go to the bathroom.
Observation on 3/13/24 at 7:55 A.M., showed another nearby resident in dining room (Resident #3) got the attention of Regional Director of Nursing and pointed to this resident and said he/she needed to go to bathroom. Regional Manager said to nearby resident (resident #3) that he/she just went.
Observation on 3/13/24 at 7:57 A.M. showed resident yelling can I please go to the bathroom. Resident is served his/her meal by the administrator.
2. Review of Resident #8's quarterly MDS, dated [DATE], showed:
-He/She had a BIMS score of 6, showed resident had severe cognitive impairment.
-He/She had clear speech and was able to make self-understood and usually understood others;
-He/She used wheelchair for mobility;
-He/She required partial to moderate assistance for toileting, upper body dressing, personal hygiene, rolling left to right, sitting to lying transfers, toilet transfers and putting on and taking off footwear;
-He/She required set up and clean up assistance for eating, oral hygiene, lower body dressing;
-He/She required substantial/maximal assistance with bathing, sitting to standing, chair to bed transfers.
Review of care plan, 11/13/22, showed:
-Ask for assistance when needing to use toilet;
-Allow me to make choices as needed;
Observation on 3/13/24 at 5:12 A.M. showed resident asking Certified Nurse Aide (CNA) C and Nurse Aide (NA) B to have a few more minutes in bed and not wanting to get out of bed. Resident asked staff three times. Each time resident would lay head back against his/her pillow. CNA C said resident had to get up in his/her wheelchair. CNA C gave resident thirty seconds to lay head against pillow then asked resident again to get up in his/her wheelchair. NA B asked resident if he/she was ready to go to breakfast and resident said he/she was not hungry.
Observation on 3/13/24 at 5:17 A.M. showed staff took resident to dining room for breakfast.
Observation on 3/13/24 at 5:35 A.M. showed resident was slouched over with head hanging down in wheelchair asleep at dining room table
Observation on 3/13/24 at 5:59 A.M. showed resident had been sitting at table with head slumped down on her chest and eyes closed.
Observation on 3/13/24 at 6:49 A.M. showed resident was asleep, head drooping down over lap. Breakfast had not been served. Resident had an empty cup of tea in front of him/her at table.
Observation on 3/13/24 at 7:25 A.M. showed resident was asleep in wheelchair at dining room table.
Observation on 3/13/24 at 7:41 A.M. showed resident head drooping far to right while asleep at dining room table with his/her head touching right arm rest with his/her forehead.
Observation on 3/15/24 at 7:05 P.M. showed resident requesting to get up and go to bathroom. Licensed Practial Nurse (LPN) B told resident he/she did not get up to use restroom. Resident continued to say I need to go to the bathroom. Staff ignored resident's request.
During an interview on 3/13/24 at 6:10 A.M., Nurse Aide (NA) B said:
-He/She started to get residents up around 5:00 A.M.;
-Resident #8 is the first to get up due to having behavioral issues of trying to get out of bed;
-He/She took Resident #8 to dining room and he/she usually sleeps in dining room until breakfast;
-If Resident refused to get up then he/she would get a different resident up and swap them out from someone on day shifts list;
-He/She was not sure who determined who was on the resident get up list.
During an interview on 3/14/24 at 9:47 A.M., CNA D said:
-It was resident's choice if they wanted to get up out of bed or not;
-Facility did have a get up list for his/her shift, however he/she just asked resident if they wanted out of bed as it was his/her right;
-If resident said no to getting up he/she would allow them to stay in bed.
During an interview on 3/14/24 at 10:15 A.M., CNA B said:
-If resident wanted to stay in bed he/she would let resident sleep in a bit then go back and check in with resident later and coax resident into going to breakfast because it was good for him/her.
3. Review of Resident #11's quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 13, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact.
-He/She had clear speech, was able to make self understood and understand others;
-He/She used walker and wheelchair for mobility;
-He/She required set up or clean up assistance with eating, oral hygiene, toileting, bathing, upper and lower body dressing, putting and taking off footwear, rolling left to right, sitting to lying, lying to sitting, sitting to standing, and with chair to bed, toilet, and tub transfers.
-Diagnoses included generalized muscle weakness, tremor (a condition causing involuntary shaking or movement), difficulty in walking, and frailty (an age-related physical debility including weakness and fatigue and reduced tolerance for medical and surgical interventions).
Review of care plan, undated, showed:
-One person to assist resident with bathing;
-Resident preferred morning bath;
-He/She preferred baths on Tuesdays and Fridays.
During an interview on 3/12/24 at 9:51 A.M., Resident said:
-He/She never knows when staff would get him/her in for a shower;
-Staff always say they will get to him/her for shower, then do not get it done;
-He/She is not getting showers first thing in the morning as he/she preferred;
-He/She used to be able to take showers before breakfast;
-He/She was getting showers twice weekly;
-He/She would prefer to take shower before breakfast;
-He/She did not think that he/she would get a shower before breakfast because facility did not have it all together.
Record review of shower preferences sheet, undated, located in 200 hall shower book showed resident preferred having showers during the day by female or male staff.
During an interview on 3/14/24 at 8:38 A.M., residents said he/she did get a shower on Tuesday but it was not until later in the afternoon.
During an interview on 3/14/24 at 10:15 A.M., CNA B said:
-He/She did not know resident's shower preferences
-He/She did not really know any resident's shower routines.
4. Review of Resident #192's facility face sheet, dated 3/15/24 showed:
-He/She was admitted [DATE];
-He/She was own responsible party;
-Diagnosis included sepsis (A life threatening complication of an infection), bacteremia (a condition with the presence of viable bacteria circulating in blood), extranodal non-hodgkin's lymphoma (a cancer that starts in lymphatic system), and epilepsy (a brain disorder that causes recurring, unprovoked seizures).
Review of care plan, undated, showed:
-Monitor my nutritional intake;
-Encourage me to have good nutritional intake for healing;
-Referall to a dietician to evaluation nutritional status as needed.
During an interview on 3/12/24 at 2:02 P.M. resident said he/she was not able to choose what he/she wanted to eat. Dietary staff just brought him/her whatever. He/She was not told if there was alternative meal options to choose from.
During an interview on 3/15/24 at 3:37 P.M., the dietary manager said:
-He/She completed dieatry likes and dislikes assessment with residents on 6/8/23;
-He/She had not done a dietary likes and dislikes assessment with Resident #192;
-Residents are served the menu for the day unless resident comes to kitchen or advises dietary staff of alternate requests;
-They educate new residents on alternatives. Cooks and aides try to greet new residents and remind them how meal's work and what alternatives are available;
-Facility had an alternative menu for residents to choose from posted in dining room;
-He/She did not have alternative menu available for vegetables.
During an interview on 3/14/24 at 10:15 A.M., CNA B said he/she did not know how meal choices were offered or determined for residents.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said he/she expected resident's choice to be honored.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to establish and maintain a system that assures a full and complete separate accounting, according to generallly accepted accounting principle...
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Based on interview and record review, the facility failed to establish and maintain a system that assures a full and complete separate accounting, according to generallly accepted accounting principles when the facility allowed the petty cash balances to have a negative balance for two months. The facility census was 40.
Facility did not provide a policy regarding resident funds accounts.
Review of the facility petty cash log showed:
-May 2023 a negative cash balance of $-92.93
-June 2023 a negative cash balance of $-73.73
Review of the facility Resident Trust Fund (RTF) bank reconciliation report showed:
-May 2023 month ending: Note at bottom of page showed petty cash starting balance was off by $100.00. Business Office Manager will take this from facility Petty Cash to refund the RTF account. Additionally, some residents accounts are negative due to surplus being deducted twice this month.
-June 2023 month ending: Check order and deposit slip order showed a shortage of RTF petty cash. Will take from regular petty cash and make deposit.
During an interview on 3/13/24 at 11:33 A.M., Business Office Manager said:
-He/She has been in position since May of last year;
-He/She did not know how or why the petty cash balance was negative;
-The accounts were messed up when he/she started in his/her position.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said there should not be a negative fund balance for petty cash.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0570
(Tag F0570)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure they submitted their current bond to the Department of Health and Senior Services (DHSS) for approval after increasing their bond a...
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Based on record review and interviews, the facility failed to ensure they submitted their current bond to the Department of Health and Senior Services (DHSS) for approval after increasing their bond amount covering the Resident Trust Fund (RTF) account. The facility census was 40.
Review of the DHSS database, which tracks the most up to date information regarding approved bonds for RTF accounts for all facilities that hold resident monies, on 3/13/24 at 1:07 P.M showed an approved bond amount of $65,000.
Review of the Resident Funds Bond Worksheet, a form used by DHSS to determine the facility's bond should be and if they have the appropriate approved amount for their bond, showed:
-The average balance for the previous twelve months in the facility's RTF bank account of $51,292.59
-After multiplying this amount by 1.5, the approved bond amount should be $76,500.
During an interview on 3/12/24 at 11:33 A.M., the business office manager said:
-The bond rider was increased on 3/12/24 to $110,000;
-He/She did not know if bond increase had been submitted to DHSS for approval.
During an interview on 3/15/24 at 7:35 P.M., Administrator said the facility's bond should be sufficient to cover the financial liability of the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that two sampled resident's (Resident #10 and #37) advance ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that two sampled resident's (Resident #10 and #37) advance directive (a legal document which allows resident to plan and make their own end-of life wishes known in the event they are unable to communicate) were clear and placed in the resident's medical record when the facility failed to show that one resident (Resident #10's) physician's orders did not show his/her code status and when one resident (Resident #37) did not have a letter of enacted incapacitation when the resident's durable power of attorney (DPOA) had a signed an Out of Hospital Do Not Resuscitate Order (OHDNR). The facility census was 40.
Facility did not provide a requested policy regarding advance directives.
1. Review of Resident #10's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/19/24, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 15, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact;
-He/She had clear speech, was able to make self-understood, and usually understood others;
-He/She used walker for mobility;
-He/She was independent with eating, oral hygiene, toileting, bathing, upper and lower body dressing, personal hygiene, and all mobility;
-Diagnoses included anxiety (a condition causing intense, excessive, and persistent worry and fear about everyday situations), depression (a condition that negatively affects how you feel, the way you think, and how you act often lowering a person's mood), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus which makes it difficult to breathe), macular degeneration (an eye disease that causes vision loss), panic disorder, legal blindness, and generalized muscle weakness.
Review of the care plan, undated, showed:
-Code status do not resuscitate (DNR)
-Honor his/her wishes to have a DNR code status;
-See physician's orders for code status;
-Ensure code status is updated yearly or with a significant change in condition.
Review of the resident's record showed the following:
-Resident's code status was not on resident's physician's orders sheet (POS) for January, February or March;
-Purple DNR sheet was dated 2/20/2020.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said:
-Staff should know the resident's code status by a green heart placed on the resident's door near their name sign is displayed;
-The resident's POS should include the residents code status.
2. Review of Resident #37's medical record showed:
- The Living Will (a written statement detailing a person's desired regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive) showed the resident named an agent to on 2/12/21;
- An Outside the Hospital Do Not Resuscitate (OHDNR) form signed by the resident's agent on 10/23/23;
- Did not have a letter of incapacity signed by two physicians.
Review of the resident's quarterly MDS, dated [DATE], showed:
- The resident had long and short- term memory problems;
- The resident was independent with eating;
- Substantial to moderate assistance with dressing the lower extremities, personal hygiene and transfers;
- Always incontinent of bowel and bladder;
- Diagnoses included cancer, dementia, anxiety and depression.
Review of the resident's undated care plan showed the resident's code status was a DNR.
Review of the resident's POS, dated March 2024 showed an order for the resident's code status as a DNR.
During an interview on 3/15/24 at 7:35 P.M., the Regional Director of Nursing (DON) said:
-It was not appropriate for a DPOA to sign DNR paperwork if the resident was still his/her own person;
-If the resident was alert and oriented he/she should sign their own Advance Directive.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said if the resident's DPOA signed the OHDNR, then there should be a letter of incapacitation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for all residents when they did not repair gouges in walls and missing paint in resident rooms (Resident #29 and #20), repair broken lights at resident's beds (Resident #11 and #20), fix and repair peeling ceiling paint in kitchen, when they did not repair a clogged sink in the memory care unit, clean vents in the ceiling of the memory care unit, clean base boards, repair large holes in parking lots, and maintain repairs in resident rooms. The facility census was 40.
Facility did not provide an environmental policy.
1. Review of Resident #11's quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 13, (a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care), showed resident was cognitively intact.
-He/She had clear speech, was able to make self understood and understand others;
-He/She used walker and wheelchair for mobility;
-He/She required set up or clean up assistance with eating, oral hygiene, toileting, bathing, upper and lower body dressing, putting and taking off footwear, rolling left to right, sitting to lying, lying to sitting, sitting to standing, and with chair to bed, toilet, and tub transfers;
-Diagnoses included generalized muscle weakness, tremor (a condition causing involuntary shaking or movement), difficulty in walking, and frailty (an age-related physical debility including weakness and fatigue and reduced tolerance for medical and surgical interventions).
Observation on 3/12/24 at 9:51 A.M. showed resident's night light was burnt out.
During an interview on 3/12/24 at 9:51 A.M., resident said facility did not have a maintenance staff and he/she did not know when his/her light could get fixed.
2. Review of Resident #20's quarterly MDS, dated [DATE], showed:
-He/She had no BIMS score completed;
-He/She required substantial/maximal assistance for eating, oral hygiene, upper body dressing,
-He/She was dependent for toileting, bathing, lower body dressing, putting on and taking off footwear, rolling left and right, sitting to lying, sit to stand, chair to bed transfers, and dependent for wheelchair transport;
-Diagnoses included mild mental retardation (a condition resulting in an IQ score of 60-69), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), osteoarthritis of knee, contracture, cognitive communication deficit, and epilepsy
Observation on 3/12/24 at 9:37 A.M. showed:
-Resident had scrapes of paint missing along wall in his/her room;
-Bathroom ceiling had water damage around the vent fan;
Observation on 3/13/24 at 5:57 A.M., showed:
-Light above resident's head of bed would not turn on when attempted to turn on for morning cares by Certified Nurse's Aides (CNA).
3. Review of Resident #29's significant changed MDS, dated [DATE], showed:
-He/She had a BIMS of 6, severely cognitively impaired.
-He/She used a wheelchair for mobility;
-He/She had clear speech and adequate hearing;
-He/She was able to make self understood and understood others;
-He/She was dependent for mobility, personal hygiene, bathing, transfers, and oral cares;
-Diagnosis included anxiety, depression, arthritis (a condition causing swelling and tenderness in one or more joints), Alzheimer's disease (a condition that destroys memory and other important mental factors), heart failure, and high blood pressure.
Observation on 3/12/24 at 10:45 A.M. showed the wall above the residents bed frame had gouges in it with paint missing.
4. Observation in facility kitchen on 3/12/24 at 8:20 A.M. showed peeling and flaking paint on the kitchen ceiling.
Observation in the kitchen on 3/14/24 at 11:49 A.M. showed the kitchen ceiling had patched drywall but not sanded, and nails poking out of ceiling with peeling paint. Paint was missing from above wall of the dish rack, and flaking paint was observed over the three compartment sink.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said:
-Facility floor, walls, and baseboards should be clean and in good repair;
-Housekeeping was responsible for cleaning baseboard and floors;
-Cleaning should be completed when items are visibly dirty;
-He/She expected maintenance to unclog sink as soon as possible;
-He/She would not expect water to sit for three days;
-Facility had been without a maintenance worker.
5. Observation on the memory care unit on 03/12/24 at 09:18 A.M., showed:
-The left side of the sink in the dining room half full of dirty water and has a strong odor;
-The vents along the whole length of the ceiling on 100 hall are covered in dirt and debris;
-The base boards along the whole length of 100 hall are dirty and scuffed in multiple areas.
During an interview on 3/12/24 at 10:17 A.M., RN A said:
-He/She did not know how long the sink had been clogged;
-He/She said maintence fixes the clogged sink;
-He/She was not sure if it had been reported;
-He/She was not sure how repairs were to be reported to maintence;
-He/She only works as needed and was not aware of the base boards or vents needing cleaned and repaired.
During an interview on 3/12/24 at 11:18 A.M., the Maintenance Supervisor said:
-The vents should be clean and in good repair;
-He/She had not cleaned the vents at this time;
-He/She was not sure often the vents were supposed to be cleaned;
-He/She was not aware the sink was stopped up on the memory care unit;
-The walls base boards in the memory care unit should be clean and in good repair.
6. Observation on 3/13/24 at 9:00 A.M., of the parking lot showed:
Right side parking lot potholes without water:
- A five foot by three foot;
- A six foot by one foot;
Right side parking lot potholes filled or partially filled with standing water:
- Two by three foot;
- Two by 1.5 foot;
- One by 1.5 foot;
- Four by two feet;
- Two by 2.5 feet;
- One by 3.5 feet;
- One foot by eight inches;
Left side parking lot potholes without water:
- Two by one foot;
- Two feet by eight inches;
- Two by 3.5 feet;
- Three by 2.5 feet;
- Seven by one foot;
- Four by five feet;
- Three by two feet;
- Five by one foot;
- Eight by eight feet;
- Five by two feet.
Left side parking lot potholes filled or partially filled with standing water:
- Four by 1.5 feet;
- Six by two feet;
- Six by eight feet;
- One by 1.5 feet;
- One by one foot;
- One foot by six inches;
- Three and a half by 1.5 feet;
- One by 1.5 feet;
- Three by three feet;
- Two by two feet;
- Three by two feet;
- One and a half by 1.5 feet;
- Three by one foot;
- Three by 2.5 feet;
Front parking lot on the left side:
- An area of 28 feet by 14 feet with pooling water;
- Within the area 8 by 5 feet area with broken/missing concrete with exposed rebar.
During an interview on 3/13/24 at 1:50 P.M., the Administrator said she started in February 2024. The former administrator had been told to get bids on the parking lot in December 2023. She was not sure if that ever happened. She did not know where the bids were if it did occur. She had not got bids since she had started as she had many other task she needed to complete.
7. Observation on 3/12/24 at 2:30 P.M., showed a crack in the walls in ceiling from the base of the wall of room [ROOM NUMBER] up the wall, through the ceiling and down the wall to the base next to room [ROOM NUMBER]. room [ROOM NUMBER] and room [ROOM NUMBER] are across the hall from one another.
8. Observation 3/12/24 starting at 2:35 P.M., showed:
- Two dents in the bathroom doorknob in room [ROOM NUMBER];
- A door knob to the bathroom bent in two places. The indentation went into the door knob a half inch and two inches respectively in room [ROOM NUMBER].
9. Observation on 3/12/24 starting at 2:35 P.M., showed:
- A one by one foot area of missing paint on the wall in room [ROOM NUMBER];
- A two foot by eight inch area of missing paint on the wall in room [ROOM NUMBER].
10. During an interview on 3/13/24 at 1:49 P.M., the Maintenance Supervisor said walls and doors need to be in good repair. Missing paint needed to be repainted and busted door knobs needed to be replace. The facility should not have large cracks that go from one side of the hallway to the other. He expected normal routine maintenance to occur to keep the building in good repair. He started as the Maintenance Supervisor on Friday (3/8/24) and he did not know how long the maintenance issues have been present in the building.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said:
-Facility floor, walls, and baseboards should be clean and in good repair;
-Housekeeping was responsible for cleaning baseboard and floors;
-Cleaning should be completed when items are visibly dirty;
-He/She expected maintenance to unclog sink as soon as possible;
-He/She would not expect water to sit for three days;
-Facility had been without a maintenance worker.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interviews and record review the facility failed to ensure residents were aware of how to file a grievance or complaint. This affected any resident who wanted to file a grievance. The facilit...
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Based on interviews and record review the facility failed to ensure residents were aware of how to file a grievance or complaint. This affected any resident who wanted to file a grievance. The facility census was 40.
The facility did not provide a policy related to grievances.
1. Review of the resident's council meeting minutes showed:
- 11/14/23 - the minutes did not indicate if the residents knew how to file a grievance;
- 12/14/23 - the minutes did not indicate if the residents knew how to file a grievance;
- 1/4/24 - the minutes did not indicate if the residents knew how to file a grievance.
During a group meeting on 3/14/24 at 2:56 P.M., five out of five residents who were alert and oriented said they did not know how to file a grievance or who the grievance officer was.
During an interview on 3/14/24 at 1:55 P.M., the Activity Director said:
- He/she had only been in that position for three weeks;
- He/she had not had a resident council meeting yet.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said:
- She always thought Social Services was the one who initiated the grievance, then they took it to the appropriate department, the response would go back to Social Services and then Social Services would follow up with the resident. She would get a copy of it to ensure it had been addressed;
- The residents should know how to file a grievance.
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #10's MDS, a federally mandated assessment tool completed by facility staff, dated 1/19/24, showed:
-He/Sh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #10's MDS, a federally mandated assessment tool completed by facility staff, dated 1/19/24, showed:
-He/She had a BIMS score of 15, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact.
-He/She had clear speech, was able to make self-understood, and usually understood others;
-He/She used walker for mobility;
-He/She was independent with eating, oral hygiene, toileting, bathing, upper and lower body dressing, personal hygiene, and all mobility;
-Diagnoses included anxiety (a condition causing intense, excessive, and persistent worry and fear about everyday situations), depression (a condition that negatively affects how you feel, the way you think, and how you act often lowering a person's mood), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus which makes it difficult to breathe), macular degeneration (an eye disease that causes vision loss), panic disorder, legal blindness, and generalized muscle weakness.
Review of MDS tracking, from 12/1/23 to 3/14/24 record showed:
-On 12/1/23 resident discharged for short term general hospital stay, he/she returned to facility on 12/6/23;
-On 2/2/24 resident discharged for short term general hospital stay, he/she returned to facility on 2/6/24.
During an interview on 3/12/24 at 11:00 A.M. resident said he/she was hospitalized in February did not remember what he/she was in hospital for. He/She did not remember signing any paperwork from facility prior to discharge.
Review of hospital discharge paperwork dated 12/4/24 showed resident was discharged after a stroke and aphasia.
Review of medical record, dated 12/1/23 to 3/12/24, showed:
-On 12/1/23 at 8:15 A.M., Certified Medication Technician (CMT) A documented the resident had right side facial drooping, slurring his/her words and EMS was contacted.
-On 2/2/24 resident was not feeling well. The residen't physician ordered to send resident to hospital for evaluation.
-On 2/6/24, resident returned to the facility from the hospital.
-Medical record contained no discharge notices;
3. Review of Resident #192's facility face sheet, dated 3/15/24 showed:
-He/She was admitted [DATE];
-He/She was own responsible party;
-Diagnosis included sepsis (A life threatening complication of an infection), bacteremia (a condition with the presence of viable bacteria circulating in blood), extranodal non-hodgkin's lymphoma (a cancer that starts in lymphatic system), and epilepsy (a brain disorder that causes recurring, unprovoked seizures).
Review of medical record, dated 3/8/24 to 3/18/24, showed:
-On 3/16/24, Resident was transferred to hospital;
-Medical record contained no discharge notices;
During an interview on 3/18/24 at 5:25 P.M., Registered Nurse (RN) F said:
-He/She completed resident's transfer and sent papers including face sheet, code status, medication, doctor's orders;
-He/She did not send transfer agreement;
4. Review of Resident #41's admission MDS, dated [DATE] showed:
- Cognitive skills intact;
- Delusions (false belief or judgment about external reality);
- Independent with eating, oral hygiene, transfers, personal hygiene, toilet use and dressing;
- Incontinent of bowel and bladder;
- Diagnoses included anxiety, high blood pressure, anemia, and depression.
Review of the resident's medical record, dated 12/19/23, showed:
-At 6:45 A.M. the resident had slurred speech and increased weakness of the right side and the physician was notified and order was received to send via EMS to the hospital;
-7:10 A.M. EMS arrived at the facility;
-7:20 AM. the resident left the facilty via EMS;
-admitted for observation;
-The resident was discharged from the facilty on 12/28/23;
-The medical record did not have a copy of any discharge letter that would have been issued to the resident.
During an interview on 3/14/24 at 1::25 P.M., Licensed Practical Nurse (LPN) A said:
-He/She sent face sheet, code status, medication, doctor's orders;
-He/She did not send transfer agreement.
During an interview on 3/14/24 at 10:32 A.M., the MDS/Care Plan Coordinator said:
- He/She has not sent any reports to the Ombudsman about transfers or discharges.
During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said:
- When they send a resident to the hospital they send the resident's face sheet, physician order sheet (POS), code status, and guardianship papers. They send a transfer form but do not send a transfer/discharge letter.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said;
- The staff send the face sheet, code status, POS, bed hold and transfer agreement. Also send any pertinent labs and the transfer form;
- They were not aware the transfer form had certain information that needed to be on the transfer/discharge letter;
- Social Services should send a monthly report to the Ombudsman with the transfers/discharges;
- Since the facility did not currently have a Social Services Designee, the Administrator should send the information to the Ombudsman.
MO233290
Based on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer of discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic nail) and telephone number of the Office of the State Long-Term Care Ombudsman, and for residents with a metal disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with metal disorders established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility must send a copy of the notice to a representative of the office of the State Long-Term Care Ombudsman. This affected four of 12 sampled residents, (Resident #1, #10, #192 and #41,). The facility census was 40.
The facility did not provide a policy regarding transfers or discharges or for notifying the State Long-Term Care Ombudsman.
1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/24 showed:
- Cognitive skills intact;
- Independent with eating, oral hygiene, transfers, personal hygiene, toilet use and dressing;
- Occasionally incontinent of urine;
- Continent of bowel;
- Diagnoses included anxiety, high blood pressure, coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart).
Review of the resident's medical record, dated 1/27/24 showed:
At 1:30 A.M. the resident had an onset of productive cough increasing with moderate sputum;
- At 3:00 A.M. the sputum became blood tinged, had trouble breathing and elevated temperature. Notified the physician and received an order to transfer the resident to the hospital be emergency medical services, (EMS). Family notified and will meet at the hospital. Vital signs obtained, temperature - 100.0, pulse - 95, blood pressure - 133/65, oxygen saturation (amount of oxygen in the blood) 75% on five liters per nasal cannula (5L/NC).
- The resident was admitted to the hospital with pneumonia ( lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid).
- On 2/5/25 at 5:36 P.M., the resident returned from the hospital;
- The medical record did not have a copy of any discharge letter that would have been issued to the resident.
During an interview on 3/14/24 at 10:32 A.M., the MDS/Care Plan Coordinator said he/she has not sent any reports to the Ombudsman regarding resident transfers or discharges.
During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said:
- When they send a resident to the hospital they send the resident's face sheet, physician order sheet (POS), code status, and guardianship papers. They send a transfer form but do not send a transfer/discharge letter.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said;
- The staff send the face sheet, code status, POS, bed hold and transfer agreement. Also send any pertinent labs and the transfer form;
- They were not aware the transfer form had certain information that needed to be on the transfer/discharge letter;
- Social Services should send a monthly report to the Ombudsman with the transfers/discharges;
- Since the facility did not currently have a Social Services Designee, the Administrator should send the information to the Ombudsman.
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 F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #10's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #10's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/19/24, showed:
--He/She had a Brief Interview Mental Status (BIMS) score of 15, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact.
-He/She had clear speech, was able to make self-understood, and usually understood others;
-He/She used walker for mobility;
-He/She was independent with eating, oral hygiene, toileting, bathing, upper and lower body dressing, personal hygiene, and all mobility;
-Diagnoses included anxiety (a condition causing intense, excessive, and persistent worry and fear about everyday situations), depression (a condition that negatively affects how you feel, the way you think, and how you act often lowering a person's mood), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus which makes it difficult to breathe), macular degeneration (an eye disease that causes vision loss), panic disorder, legal blindness, and generalized muscle weakness.
Review of MDS tracking, from 12/1/23 to 3/14/24 record showed:
-On 12/1/23 resident discharged for short term general hospital stay, he/she returned to facility on 12/6/23;
-On 2/2/24 resident discharged for short term general hospital stay, he/she returned to facility on 2/6/24.
During an interview on 3/12/24 at 11:00 A.M. resident said he/she was hospitalized in February did not remember what he/she was in hospital for. He/She did not remember signing any paperwork from facility prior to discharge.
Review of hospital discharge paperwork dated 12/4/24 showed resident was discharged after a stroke and aphasia.
Review of resident's medical record, dated 12/1/23 to 3/14/24, showed:
-On 12/1/23 at 8:15 A.M., CMT A wrote resident had right side facial drooping and slurring words and EMS was contacted. Report called to hospital by RN.
-On 1/30/24 resident was on isolation for Covid-Sars-19;
-On 2/2/24 resident was not feeling well. Ordered to send resident to hospital for evaluation.
-On 2/6/24, resident returned from hospital.
-The medical record did not have a copy of any bed hold letter that would have been issued to the resident.
3. Review of Resident #192's facility face sheet, dated 3/15/24 showed:
-He/She was admitted [DATE];
-He/She was own responsible party;
-Diagnosis included sepsis (A life threatening complication of an infection), bacteremia (a condition with the presence of viable bacteria circulating in blood), extranodal non-hodgkin's lymphoma (a cancer that starts in lymphatic system), and epilepsy (a brain disorder that causes recurring, unprovoked seizures).
Review of medical record, dated 3/8/24 to 3/18/24 showed:
-On 3/16/24, resident was transferred to the hospital.
-The medical record did not have a copy of any bed hold letter that would have been issued to the resident.
During an interview on 3/18/24 at 5:25 P.M., Registered Nurse (RN) F said:
-He/She completed resident's transfer and sent papers including face sheet, code status, medication, doctor's orders;
-He/She did not send bed hold agreement;
During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said he/she did not know about the bed hold letters.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said a bed hold letter should be sent with the resident when they are transferred to the hospital and it should be signed by the resident or responsible party.
MO233290
Based on interviews and record review, the facility failed to inform residents and their family/legal representatives of the bed hold policy at the time of the transfer/discharge to the hospital for three of 12 sampled residents, (Resident #1, Resident #10 and Resident #192) and failed to have the resident or family/legal representative sign the bed hold which affected Resident #1. The facility census was 40.
The facility did not provide a policy regarding bed holds.
1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/24 showed:
- Cognitive skills intact;
- Independent with eating, oral hygiene, transfers, personal hygiene, toilet use and dressing;
- Occasionally incontinent of urine;
- Continent of bowel;
- Diagnoses included anxiety, high blood pressure, coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart).
Review of the resident's medical record, dated 1/27/24 showed:
At 1:30 A.M. the resident had an onset of productive cough increasing with moderate sputum;
- At 3:00 A.M. the sputum became blood tinged, had trouble breathing and elevated temperature. Notified the physician and received an order to transfer the resident to the hospital be emergency medical services, (EMS). Family notified and will meet at the hospital. Vital signs obtained, temperature - 100.0, pulse - 95, blood pressure - 133/65, oxygen saturation (amount of oxygen in the blood) 75% on five liters per nasal cannula (5L/NC).
- The resident was admitted to the hospital with pneumonia ( lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid).
- On 2/5/25 at 5:36 P.M., the resident returned from the hospital;
- The medical record did not have a copy of any bed hold letter that would have been issued to the resident.
Review of the resident's bed hold notice, dated 1/27/24 showed:
- The form had the resident's name, the name of the facility and instructed to notify the Administrator with the facility's phone number;
- The form was not signed by the resident or the responsible party.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care ...
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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 plan of care to include measurable objectives and appropriate timeframe's for two of 12 sampled residents (Resident #33 and Resident #36). The facility census was 40.
The facility did not provide the requested comprehensive care plan policy.
1. Review of Resident #33's Quarterly MDS dated , 1/7/24, showed:
-Severe cognitive impairment;
-The resident has delusions (false beliefs or judgments about reality);
-Limited assistance with ADLs;
-Diagnosis included, Dementia, diabetes mellitus (a metabolic disease, involving elevated blood sugar levels), and heart failure.
Review of the resident's POS, dated March 2024, showed:
- Activities - per care plan
- Start date: 4/26/23 - Novolog( rapid-acting insulin), 5 units three times before meals for diabetes mellitus. Call the physician if blood sugar is less than 60 or greater than 400.
Review of the resident's undated care plan showed:
-Limited assistance with ADLs;
-The resident's care plan did not address diabetes care/treatment.
During an interview on 3/14/24 at 9:05 A.M., the MDS Coordinator said:
-The resident care plans should address shower and shaving preferences;
-If the resident often refuses showers and shaving that should be on the care plan;
-The care plan should address the resident's activity preferences;
-He/she has only been MDS Coordinator for a few weeks and is trying to get the care plans up to date.
2. Review of Resident #36's Quarterly MDS, dated [DATE] showed:
- Cognitive skills intact;
- Independent with eating, dressing, personal hygiene, toilet use and transfers;
- Always continent of bowel and bladder;
- Diagnoses included stroke, hemiplegia (paralysis affecting one side of the body), diabetes mellitus, anxiety and depression.
Review of the resident's POS, dated March 2024, showed:
- Diet - regular, regular texture, thin liquids and double protein with meals;
- Activities - as tolerated;
- Start date: 9/1/23 - Lantus insulin (long-acting), 15 units at bedtime for diabetes mellitus. Call the physician if blood sugar is less than 60 or greater than 400.
Review of the resident's undated care plan showed it did not address the resident's activity preferences, the use of insulin or the resident's diet.
During an interview on 3/14/24 at 10:32 A.M., the MDS/Care Plan Coordinator said:
- He/she had been in the current position since 2/21/24;
- The care plan should address the use of insulin, activities and the resident's diet.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said the care plan should address the use of insulin, the resident's diet, activities and shower and shaving preferences.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff utilized an Inter Disciplinary Care Te...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff utilized an Inter Disciplinary Care Team to developed and updated a care plan consistent with resident's specific conditions and needs which affected two of 12 sampled residents, (Resident #10 and #1) when they did not update care with interventions regarding unexpected weight loss for (Resident #10) and when they did not include residents (Resident #1) in his/her care planning. The facility census was 40.
Review of Resident #10's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/19/24, showed:
--He/She had a Brief Interview Mental Status (BIMS) score of 15, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact.
-He/She had clear speech, was able to make self-understood, and usually understood others;
-He/She used walker for mobility;
-He/She was independent with eating, oral hygiene, toileting, bathing, upper and lower body dressing, personal hygiene, and all mobility;
-Diagnoses included anxiety (a condition causing intense, excessive, and persistent worry and fear about everyday situations), depression (a condition that negatively affects how you feel, the way you think, and how you act often lowering a person's mood), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus which makes it difficult to breathe), macular degeneration (an eye disease that causes vision loss), panic disorder, legal blindness, and generalized muscle weakness.
Review of physician's orders, dated March 2023, showed:
-Resident on mechanical soft and fortified foods.
-Bedtime snack
-Mighty Shake
Review of care plan, undated, showed:
-He/She was at risk for pressure ulcers, skin tears, and skin breakdown;
-His/Her nutritional intake was compromised;
-He/She had diagnosis of gastroparesis;
-He/She had many things he/she could not eat;
-He/She will make self throw up by putting finger down his/her throat;
-Refer to dietician to evaluate resident nutritional status;
-Encourage him/her to have good nutritional intake
-Offer me supplemental nutritional support as orders and as needed
-Did not update care plan with significant weight loss concerns.
Review of care plan conference summary, dated 1/31/24, showed the residents appetite had decreased since 1/26/24. No care interventions added to the care plan.
Review of medical record showed:
-12/4/24, social service wrote facility called liberty hospital and resident had a stroke. Resident was not eating well with an upset stomach. Want to figure that out before discharged .
-12/6/24, social service wrote resident was being discharged from Liberty Hospital.-Hospital discharge orders showed diet of no pork, limited fried foods, no raw veggies, low/fiber/low residue. Vanilla ensure with breakfast.
-2/8/24, the resident weighed 120.8lbs and on 3/1/24 the resident weighed 106.7lbs
-No nurses notes found in chart to show resident / physician was notified of weight loss from 3/11/ 23 weight change.
-Review of vital signs showed: On 02/08/2024, the resident weighed 120.8 lbs. On 03/01/2024, the resident weighed 106.7 pounds which is a -11.67 % Loss
Review of physician notes showed:
-On 3/12/24, Resident had Covid-Sars-19 at end of January. She continues to have some chronic nausea along with occasional vomiting. She sometimes has difficulty swallowing. She now has an appointment for gastrointensitnal doctor for May 1, 2024.
Review of registered dietary assessments showed:
-On 1/18/23, recommend interventions for nutrition care.
-On 2/12/24, resident was down two pounds in 1 month, down 9 pounds in 3 and 6 months. On fortified diet and 1 mighty shake. Supply weekly weights to once a month.
Review of MARS March 2024 showed mighty shake orders with no entry on 3/4, 3/8, and 3/9.
During an interview on 3/12/24 at 10:51 A.M. resident said he/she was on a low fiber, no fried food, no pork, so makes it hard for him/her to eat what was on menu.
Review of facility provided matrix, dated 3/15/24, did not show resident having any significant weight loss.
During an interview on 3/15/24 at 8:41 A.M., the Assistant Director of Nursing (ADON) said:
-The staff do not document resident's food intake anywhere;
-There is not a progress note everyday regarding resident food intake.
During an interview on 3/15/24 at 9:38 A.M. the dietician said:
-He/She would expect facility to contact him/her with significant changes with residents;
-He/She would have recommended supplements for the resident due to significant weight loss;
-He/She did not participate in care plan meetings at the facility.
During an interview on 3/15/24 at 10:04 A.M., Administrator said:
-Facility staff should have contacted the dietician and physician with significant weight loss;
-Care team should have reviewed and evaluated the residents weights;
-The dietician would have discussed with team on ways to get resident to eat;
-Unexpected weight loss should be care planned;
-When residents experience a significant weight change, he/she would expect nursing staff to notify the physician;
-He/She would have expected resident to be re-weighed on the same date to ensure weight was accurate.
During an interview on 3/15/24 at 1:32 P.M. the physician said:
-He/She would expect the facility to contact him/her with significant weight loss;
-He/She was not aware of resident having any significant weight loss recently;
2. Review Resident #1's medical record showed:
- admission date: 12/31/20;
- readmission date: 5/11/23.
Review of the resident's care plan conference summary, dated 11/30/22 showed the form was not signed by the resident or the resident's representative to indicate they had attended the meeting.
Review of the resident's care plan conference summary, dated 2/8/23 showed the form was not signed by the resident or the resident's representative to indicate they had attended the meeting.
Review of the resident's care plan conference summary, dated 6/28/23 showed the form was not signed by the resident or the resident's representative to indicate they had attended the meeting.
Review of the resident's Quarterly MDS, dated [DATE] showed:
- Cognitive skills intact;
- Independent with eating, oral hygiene, transfers, personal hygiene, toilet use and dressing;
- Occasionally incontinent of urine;
- Continent of bowel;
- Diagnoses included anxiety, high blood pressure, coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart).
Review of the resident's care plan conference summary, dated 1/10/24 showed the form was not signed by the resident or the resident's representative to indicate they had attended the meeting.
During an interview on 3/12/24 at 9:18 A.M., the resident said he/she could not remember if he/she had been invited to a care plan meeting or not and would like to participate in development of his/her plan of care.
During an interview on 3/14/24 at 11:11 A.M., MDS/Care Plan Coordinator said:
- He/she had been in the position since 2/21/24;
- He/she planned to schedule care plan meetings based on the MDS calendar;
- There's a place at the bottom of the care plan conference summary where the resident and /or the resident's representative should sign when they attend the meeting.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said:
- The resident's should be invited to the care plan meetings;
- The staff should provide an invite to the reisdent/family and have them sign in if they attend;
- Should have note in the care plan about the resident attending the meeting.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #33's Quarterly MDS dated , 1/7/24, showed:
-Severe cognitive impairment;
-The resident has delusions (fal...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #33's Quarterly MDS dated , 1/7/24, showed:
-Severe cognitive impairment;
-The resident has delusions (false beliefs or judgments about reality);
-Limited assistance with Activities of Daily Living (ADLs);
-Diagnosis included, Dementia, diabetes mellitus (a metabolic disease, involving elevated blood sugar levels), and heart failure.
Review of the resident's undated care plan showed:
-Limited assistance with ADLs;
-The resident's care plan did not address diabetes.
Review of the resident's POS, dated March 2024 showed:
- Start date: 4/26/23 - Accu check three times a day before meals and at bed time.
Review of the resident's MAR, dated March 2024 showed accu check three times a day before meals and at bedtime.
Observation on 3/13/24, at 07:51 A.M., showed:
-The resident eating breakfast in the dining room;
-The resident finished eating his/her eggs and was eating a bowl of oatmeal when Licensed Practical Nurse, (LPN) A said he/she needed to obtain the resident's blood sugar;
-The resident said he/she wanted to finish his/her breakfast first and he/she continued to finish the bowl of oatmeal;
-The resident went back to his/her room with LPN A;
-The LPN A obtained the resident's blood sugar;
-The resident's blood sugar was 138;
-LPN A gave the resident 7 units of insulin.
During an interview on 3/14/24 at 8:32 A.M., LPN A said:
- If the order said to obtain the resident's blood sugar before meals;
- He/she should have obtained the resident's blood sugar before he/she was eating because the accu check would not be accurate.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said accu checks should be obtained before meals not after the resident has eaten.
Based on observations, interviews, and record review the facility failed to ensure staff followed professional standards of care when staff failed to administer medications with food, which affected three of 12 sampled residents, (Resident #7, Resident #15 and Resident #33). The facility census was 40.
Review of the facility's policy for administering medications, revised April 2019, showed, in part:
- Medications are administered in a safe and timely manner, and as prescribed;
- Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/24 showed:
- Cognitive skills intact;
- Independent with eating, personal hygiene, toilet use, dressing and transfers;
- Diagnoses included high blood pressure, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood flow to the kidneys caused by renal artery disease), arthritis, anxiety and depression.
Review of the resident's physician order sheet (POS), dated March 2024 showed:
- Start date: 4/15/23 - Allopurinol 300 milligrams (mg.) one tab with food daily for gout.
Review of the resident's medication administration record (MAR), dated March 2024 showed:
- Allopurinol 300 mg. one tab with food daily for gout.
Observation on 3/13/24 at 7:38 A.M., showed:
- Certified Medication Technician (CMT) A left the medicine cup with the resident's medication in it because the resident was sleeping.
2. Review of Resident #15's Annual MDS, dated [DATE] showed:
- Cognitive skills severely impaired;
- Independent with eating and transfers;
- Partial/moderate assistance with toilet use and personal hygiene;
- Supervision or touching assistance with dressing;
- Diagnoses included coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart), high blood pressure, diabetes mellitus, dementia, traumatic brain injury (TBI, a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury), depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing).
Review of the resident's POS, dated March 2024 showed:
- Start date: 1/9/18 - Enteric coated aspirin (ECASA) one tab daily with food for prophylaxis;
- Start date: 4/19/23 - Metformin HCL 500 mg. one tab with food twice daily for diabetes mellitus.
Review of the resident's MAR, dated March 2024 showed:
- Enteric coated aspirin (ECASA) one tab daily with food for prophylaxis;
- Metformin HCL 500 mg. one tab with food twice daily for diabetes mellitus.
Observation on 3/13/24 at 7:49 A.M., showed the resident was asleep but woke up and CMT A gave the resident his/her medication with water, no food and the resident laid back down and went to sleep.
During an interview on 3/14/24 at 1:41 P.M., CMT A said if the order said for the residents to take their medication with food, then he/she should have made sure they took their medication with food.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said if the order said for the resident to take the medication with food, staff should have something right there on their cart to give the resident.
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** 4. Review of Resident #8's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #8's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/7/24, showed:
-He/She had a BIMS score of 6, indicating resident had severe cognitive impairment.
-He/She had clear speech and was able to make self-understood and usually understood others;
-He/She used wheelchair for mobility;
-He/She required partial to moderate assistance for toileting, upper body dressing, personal hygiene, rolling left to right, sitting to lying transfers, toilet transfers and putting on and taking off footwear;
-He/She required set up and clean up assistance for eating, oral hygiene, lower body dressing;
-He/She required substantial/maximal assistance with bathing, sitting to standing, chair to bed transfers.
Review of undated care plan showed:
-He/She required assistance from staff to complete daily activities of care safely related to dementia/impaired mobility
-Staff are directed to assist the reisdent to brush his/her teeth/oral care
-Staff are directed to assist the resident with his/her hair.
Review of the residents medical record showed:
-On 2/12/24 resident was seen by dental hygienist with following instructions for staff:
-Please remind/assist resident to brush twice daily, focusing at gum line;
-Please remind/assist resident with removing dentures nightly, soak in denture bath: water with denture cleaning tablet. Brush with denture brush in A.M. Daily removal and cleaning is important to reduce the risk of bacterial infection. If adhesive is needed, dry denture with tissue, apply 3 pea sized drops of adhesive, then swish with water to aid in suction.
Observation on 3/13/24 showed NA B and CNA C assist the resident out of bed and assisted with dressing. CNA C brushed residents hair. No oral care was provided to resident.
During an interview on 3/13/24 at 6:10 A.M., Nurse Aide B said he/she did not provide oral care to resident that morning because he/she was running behind.
During an interview on 3/13/24 at 6:11 A.M., Certified Nurse Aide (CNA) C said he/she did not provide oral care to resident.
Observation on 3/14/24 at 8:05 A.M. showed resident was wheeled to dining room with hair matted up in back from being in bed and was going in all different directions and had not been brushed.
5. Review of Resident #20's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/12/24, showed:
-He/She had a BIMS score of 11, showed resident had mild cognitive impairment.
-He/She used wheelchair for mobility;
-He/She required set up or clean up assistance with eating, oral hygiene
-He/She required partial/moderate assistance with toileting, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene,
-Diagnoses included disk degeneration of lumbosacral region, mild mental retardation (a condition resulting in an IQ score of 60-69), bipolar disease (a disorder associated with mood swings ranging from depressive lows and manic highs), epilepsy (a brain disorder that causes recurring, unprovoked seizures)
Review of undated care plan showed:
-Resident has poor dental health, she has her own teeth. Sometimes will not want to see the dentist. She does not complain of dental pain.
-Resident will be free of mouth pain/discomfort through the next review.
-Make a dental appointment for resident for a dental exam as needed
-Encourage resident to do good oral care
-Assist resident with oral care to reduce irritation from food, and to assure if it done.
-Monitor resident's gums for irritation or sores
-Weigh monthly or as ordered.
-Resident required assistance from staff with all her activities of daily living
-Resident was dependent on two staff for bathing;
-He/She preferred baths on Mondays and Thursday evenings;
Review of medical record showed:
-On 2/21/24 resident was seen by dental hygienist with the following instructions for staff:
-Please remind and assist resident to brush teeth twice daily focusing on gum line.
Review of shower logs, dated 11/9/23 to 3/15/24, showed:
-Resident had 16 of 39 opportunities for showers.
-Showers were documented on 11/9/23, 11/13/23, 11/25/23, 12/2/23, 12/7/23, 12/14/23, 12/21/23, 12/28/23, 1/4/24, 1/8/24, 1/11/24, 2/5/24, 2/9/24, 2/22/24, 3/4/24, and 3/11/24.
Observation on 3/12/24 at 9:45 A.M. showed resident had long hair that appeared greasy and unkept.
Observation on 3/13/24 at 5:47 A.M. showed CNA C and NA B assisting resident with morning routine of getting dressed and out of bed. No oral care was provided to resident. Resident was not assisted with having face washed. Resident's hair was not brushed.
Observation on 3/12/24 at 9:44 A.M. showed a plastic bag with the residents name on it dated 3/2/24 with a new toothbrush in a sealed package and new tube of tooth paste that had not been opened.
During an interview on 3/13/24 at 6:10 A.M., CNA C said:
-He/She did not provide resident oral care this morning;
-He/She did not brush resident's hair this morning, the resident had a shower the previous night and resident can try to fight staff during cares.
During an interview on 3/13/24 at 6:11 A.M., NA B said he/she had not provided oral care or hair care to the resident that morning.
During an interview on 3/13/24 at 6:10 A.M., CNA C said oral care was provided most mornings but today he/she was running behind today and did not do it.
During an interview on 3/15/24 at 7:35 P.M., Administrator said oral care should be provided in the mornings and at bedtime and per resident's preferences.
MO231714
MO232414
Based on observation, interview, and record review, the facility failed to ensure residents who required assistance with Activity of Daily Living (ADL) received the necessary assistance with grooming, bathing and incontinent care when the facilty staff failed to ensure three residents (Resident #36, Resident #142, and Resident #20) received regular showers, failed to provide complete incontinence care for one resident (Resident #37), and when staff failed to provide oral care to two resident (Resident #8 and #20). The facility census was 40.
Review of the facility's Activities of Daily Living (ADL) policy revised March 2018, showed:
-Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good grooming, oral care and personal hygiene;
-Appropriate care and services that will be provide include bathing, dressing, grooming, oral care and toileting.
The facilty staff did not provide a policy regarding incontinence care.
1. Review of Resident #142's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/24 showed:
- Severe cognitive impairment;
- Assistance of one staff with eating, oral hygiene, dressing, toilet use, and personal hygiene.
- Supervision with showers;
- Occasionally incontinent of bowel and bladder;
- Diagnoses included dementia, high blood pressure and depression.
Review of Resident #142's medical record showed:
-admitted [DATE];
-3/5/24 the resident had a shower;
-No other documenttion or shower sheets were found.
Review of the resident's undated care plan, showed:
- The resident required assistance to complete daily activities of care due to dementia;
- Provide assistance with bathing;
- Shower resident per schedule.
- He/she preferred showers on Tuesday and Friday evenings;
- The resident's care plan did not address shaving or oral care.
Observation on 3/12/24 at 10:16 A.M., showed:
- The resident has facial hair;
- The resident's hair is greasy and unkempt;
- The resident has foul breath odor.
Observation on 3/14/24 at 8:32 A.M., showed:
- The resident has facial hair;
- The resident's hair continues to be greasy and unkempt;
- The resident continues to have foul breath odor.
During an interview on 3/14/24 at 11:07 A.M., Certified Nurses Aide (CNA) D said:
- He/she just started 3/11/24 and has not worked on the memory care unit before;
- He/she did not know the routine and who gave the showers or when;
- The resident should receive a shower at least once week;
- He/she did not know the last time the resident was shaved.
During an interview on 3/15/24 at 10:22 A.M., Licensed Practical Nurse (LPN) A said:
-The resident is new and admitted on [DATE];
-The staff try to shave and shower the resident when the resident chooses;
- If the resident refuses assistance staff re-approach the reisdent at a later time;
- Residents should be clean and well groomed;
-Residents should be showered at least once a week and shaved when they choose.
2. Review of Resident #36's shower sheets for November, 2023 showed:
- 11/3/23- the resident had a shower;
- 11/9/23- the resident had a shower;
- 11/17/23- the resident had a shower;
- 11/22/23- the resident had a shower.
Review of the resident's quarterly MDS, dated [DATE] showed:
- Cognitive skills intact;
- Independent with eating, oral hygiene, dressing, toilet use, personal hygiene, and transfers;
- Supervision or touch assistance with showers;
- Always continent of bowel and bladder;
- Diagnoses included stroke, hemiplegia (paralysis affecting one side of the body), diabetes mellitus, anxiety and depression.
Review of the resident's shower sheets for December, 2023 showed:
- 12/8/23- the resident had a shower;
- 12/14/23- the resident had a shower;
- 12/16/23- the resident had a shower;
- 12/21/23- the resident had a shower.
Review of the resident's shower sheets for January, 2024 showed:
- 1/6/24- the resident had a shower;
- 1/13/24- the resident had a shower;
- 1/17/24- 1/13/24- the resident had a shower;
- 1/20/24- the resident had a shower;
- 1/13/24- the resident had a shower.
Review of the resident's shower sheets for February, 2024 showed:
- 2/4/24- the resident had a shower;
- 2/9/24- the resident had a shower;
- 2/18/24- the resident had a shower;
- 2/28/24- the resident had a shower.
Review of the resident's shower sheets for March 1 to March 15, 2024 showed:
- 3/2/24- the resident had a shower;
- 3/11/24- the resident had a shower.
Review of the resident's undated care plan, showed:
- The resident required assistance to complete daily activities of care safely related to stroke with right sided weakness;
- Provide assistance to gather items for bathing and assist to bathing area as needed;
- Encourage the resident to wash, rinse, and dry the areas of his/her body that are within the resident's physical ability;
- Bathe resident per schedule. He/she preferred showers on Wednesday and Saturday evenings.
During an interview on 3/14/24 at 7:47 A.M., the resident said:
- He/she does not always get their showers twice a week on Wednesday and Saturdays;
- It made him/her feel like dirt and not important enough for the staff to take care of him/her;
- It made him/her feel neglected.
During an interview on 3/14/24 at 1:34 P.M., CNA B said:
- The facility did not have a dedicated shower aide;
- The staff provide showers on days and the evening shifts;
- He/she did not know if staff provide showers on the weekends.
During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said:
- They did not have a dedicated shower aide;
- The staff fill out the shower sheets when the showers are completed, turn them into the Charge Nurse (CN) who should review them, sign them and turn them into the DON;
- If a resident missed their shower, the staff should try and do it on the next shift;
- The CNAs and the CNs should pass it on in report if a resident missed their shower.
During an interview on 3/15/24 at 9:57 A.M., Nurse Aide (NA) A said;
- They do not have a dedicated shower aide;
- If a shower did not get completed, they pass it on on to the next shift or they are added to the next day;
- They fill out the shower sheets and turn them into the CN at the end of their shift for the CNs to sign.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said:
- The facility did not have a dedicated shower aide;
- If a resident missed their shower, the next shift coming on should attempt to do it and if they can't, then it should be added to schedule for the next day;
- She would expect the residents to get their showers twice weekly or as they desired.
3. Review of Resident #37's quarterly MDS, dated [DATE] showed:
- Long and short term memory problems;
- Independent eating;
- Supervision or touch assistance with oral hygiene;
- Partial to moderate assistance with toilet use, showers and dressing the upper body;
- Substantial to moderate assistance with dressing the lower extremities, personal hygiene and transfers;
- Always incontinent of bowel and bladder;
- Diagnoses included cancer, other fracture, dementia, anxiety and depression.
Review of the resident's undated care plan showed:
- The resident is frequently incontinent of urine and bowel;
- Staff are directed to assist with perineal cleansing as needed.
Observation on 3/13/24 at 6:49 A.M., showed:
- CNA B and NA A washed their hands and applied gloves;
- CNA B uncovered the resident and fecal material was note on the top sheet and cover, which was folded back at the foot of the bed;
- CNA B cleaned the residents hands and fingernails with wipes to removed the fecal material;
- CNA B used multiple wipes to clean the resident's buttocks with fecal material noted and folded the wipes with fecal material on them. CNA B used the same area of the wipe to clean different areas of the buttocks and to remove dried fecal material from the skin;
- CNA B and NA A turned the resident onto his/her back;
- NA A removed the soiled linens from the bed and placed them directly on the floor;
- CNA B removed his/her gloves, did not wash his/her hands and applied new gloves;
- CNA B did not separate and clean all the front perineal folds;
- CNA B and NA A placed a clean incontinent brief on the resident;
- NA A and CNA B removed gloves, did not wash and applied new gloves;
- NA A and CNA B dressed the resident and used the mechanical lift to transfer the resident from the bed to his/her broda chair (a type of reclining geri chair);
- NA A brushed the resident's hair;
- CNA B took the resident to the dining room and did not wash the resident's face or hands and did not provide oral care.
During an interview on 3/14/24 at 1:34 P.M., CNA B said:
- He/she should not have folded the wipe when cleaning the fecal material, it should be one wipe, one swipe;
- Should not use the same area of the wipe to clean different areas of the skin;
- Should have separated and cleaned all areas of the skin where urine or feces has touched;
- Should have washed the resident's face and hands and provided oral care before taking the resident to the dining room.
During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said:
- Staff should separate and clean all areas of the skin where urine or feces had touched, should not use the same area of the wipe to clean different areas of the skin. Staff should not fold the wipe when cleaning fecal material;
- When staff get residents up in the morning, they should wash the resident's face, comb their hair, clean their eye glasses, and offer or provide oral care.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said:
- Staff should separate and clean all areas of the skin where urine or feces had touched;
- Staff should not fold the wipe when cleaning fecal material;
- Staff should not use the same area of the wipe to clean different areas of the skin, it should be one wipe, one swipe.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 provide an ongoing program to support residents in the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident when residents were not offered activities. This affected four residents (Residents #2, #30, #36 and #142) out of 12 sampled residents. The facility census was 40.
Review of the facility's Activities Programs, revised June 2018, showed:
-Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well being of each resident;
-The activities is provided to support the well-being of resident's and to encourage independence community interaction;
-Activities are based on the comprehensive resident-centered assessment and the preferences of each resident;
-The activities program is ongoing and includes facilty organized group activities, independent individual activities and assisted individual activities;
-Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, clan up and critique of the programs;
-All activities are documented in the resident's medical record;
-Activity participation for each resident approved by the attending physician based on information in the residents comprehensive assessment;
-Scheduled activities are posted on the resident's bulletin board, activity schedules are also provided individually to resident's who cannot access the bulletin board;
-Individualized and group activities that, reflect the choices, schedules and rights of residents;
-Activities that appeal to men and women as well as various age groups;
-Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met.
Review of the activities calendar posted the refrigerator dated March, 2024 showed:
-3/12/24: 10:00 A.M. - Nails (200 hall), 1:00 P.M., mail, 2:00 P.M., nails;
-3/13/24: 10:00 A.M. - Bingo 1:00 P.M., nails;
-3/14/24: 10:00 A.M. - 1:00 P.M. Mail, 2:00 P.M., resident council;
-3/15/24: 10:00 A.M. - Bingo, Mail 1:00 P.M.,
-3/16/24: The day was blank, no activities were on the calendar.
1. Review of Resident #2's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/12/24, showed:
- Cognitive skills moderately impaired;
- Diagnoses included dementia, high blood pressure, heart failure and anxiety.
- Limited assistance with bed mobility, transfers, and dressing;
- Doing things with groups of people is important to him/her;
Review of the resident's care plan, dated 12/21/23, showed:
-Assistance of one staff member for Activities of Daily Living (ADL's);
-The care plan did not address activities.
Review of the resident's Activity Participation record dated November 2023 through March 2024 showed:
-Entries for group activities on 11/1/23 through 11/20/23;
-No one to one programming was found;
-No other activity participation sheets were found.
2. Review of Resident #30's Quarterly MDS, dated [DATE], showed:
- Cognitive skills severely impaired;
- Limited assistance with bed mobility, transfers, and dressing;
- Hearing moderately impaired;
- Frequently incontinent of bowel and bladder;
- Doing things with groups of people is important to him/her;
- Diagnoses included Alzheimer's Disease, high blood pressure, anxiety.
Review of the resident's undated care plan showed:
-Requires limited assistance of one staff member for ADL's;
-The resident is hard of hearing;
-Encourage the resident to participate in activities as a therapeutic distraction;
-Involve the resident in activities as he/she can tolerate.
Review of the resident's Activity Participation record dated November 2023 through March 2024 showed:
-Entries for group activities on 11/1/23 through 11/20/23;
-No one to one programming was found;
-No other activity participation sheets were found.
3. Review of Resident #142's admission MDS, dated , 2/13/24 showed:
-Supervision of staff with ADL's;
-Severe cognitive impairment;
-Occasionally incontinent of bowel and bladder;
-Doing things with groups of people are important to the resident;
-Diagnoses included dementia, high blood pressure and anxiety.
Review of the resident's care plan dated 2/29/24, showed:
-Difficulty recalling events;
-Prefers evening showers;
-Needs assistance with showers;
-Ask the resident about his/her preferences throughout the day;
-The care plan did not address activity preferences for the resident.
Review of the resident's Activity Participation record dated February 2023 through March 2024 showed:
-No entries for group activities;
-No one to one programming was found;
-No other activity participation sheets were found.
Observations 3/12/24 through 3/15/24 at various times from 8:00 A.M. to 5:30 P.M., showed:
-There were no activities in progress on the memory care unit;
-There were no 1:1 activities in progress on the memory care unit;
-Resident #30 wandering up and down the halls with no staff visible on hall where the resident was wandering;
-Resident #142 setting in the dinging room watching TV;
-Resident #2 in his/her room with no staff offering activities.
During an interview on 3/14/24 at 7:16 A.M., Certified Nurses Aide (CNA) D said:
-This was his/her first day on the memory care unit;
-He/she started at the facility last week;
-He/she did not know what group activities the residents did or what individual activities each resident liked;
-He/she did not know where to look for this information but he/she could a a nurse.
During an interview on 3/14/24 at 7:28 A.M., Nurses Aide C said:
-He/she just started working at the facility last week;
-This is only his/her second or third day on the memory care unit;
-The residents play bingo on the other halls;
-Sometimes staff will pass out coloring pictures;
-There is only on staff that works down here so it is hard to set do activities and do other things that need to be done.
4. Review of the resident #36's Quarterly MDS, dated [DATE] showed:
- Cognitive skills intact;
- Independent with eating, oral hygiene, dressing, toilet use, personal hygiene, and transfers;
- Supervision or touch assistance with showers;
- Always continent of bowel and bladder;
- Diagnoses included stroke, hemiplegia (paralysis affecting one side of the body), diabetes mellitus, anxiety and depression.
Review of the resident's undated care plan showed it did not address the resident's activity preference.
Review of the resident's activity record showed:
- 12/19/23 at 1:30 P.M., the resident attended movie and popcorn;
- 12/21/23 at 2:00 P.M., the resident attended birthday cake and party;
- 12/22/23 at 2:00 P.M., the resident attended movie and popcorn;
- 1/5/24 at 2:00 P.M., the resident attended movie and a banana split;
- 1/10/24 at 2:00 P.M., the resident attended fidget and conversing cards;
- 1/12/24 at 2:00 P.M., the resident attended movie and popcorn;
- 1/13/24 at 7:00 P.M., the resident attended the Chiefs part, popcorn, chips and soda;
- 1/19/24 at 2:00 P.M., the resident attended a movie and strawberry shortcake.
During an interview on 3/14/24 at 12:25 P.M., the resident said:
- He/she did not usually go to the activities because they were mostly for women;
- They do not usually do any activities for the men.
During an interview on 3/14/24 at 9:48 A.M., the Activities Director said:
-He/she just started a few weeks ago;
-The residents on the memory care unit need activities during the day;
-The previous activity director left a few months a go and there is no record of activities during that time;
-He/she is trying to get an activity program together for all residents;
-He/she is trying to get 1:1 activities for the residents.
During an interview on 3/15/24 at 05:28 P.M., the Administrator said:
-Activities should be based on each resident's developmental and cognitive abilities;
-Activities should be recorded by the activity director;
-There should be activities for men also;
-The facility was without an activity director for the last few months;
-The activity director is expected to plan and direct group actives and one on one programming for all residents including residents on the special care unit as well as for the whole facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interviews, and record review, the facility staff failed to provide repositioning and incontinent care accord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interviews, and record review, the facility staff failed to provide repositioning and incontinent care according to professional standards of practice for three residents (Resident #3, #18, and #37) who were dependent upon staff for mobility and assistance with cares. This affected three of twelve sampled residents. The facility census was 40.
Facility did not provide the requested policy regarding positioning.
1. Review of Resident #3's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/25/24, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 7, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was severely cognitively impaired.
-He/She had clear speech, usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time;
-He/She usually understands but misses some part or intent of message but comprehends most conversation;
-He/She was independent with eating and oral hygiene;
-He/She was dependent for toileting, bathing, lower body dressing, putting and taking off footwear, personal hygiene, mobility from lying to sitting, sitting to stand, and chair to bed transfers, and transfers to toilet or shower.
-Diagnoses included dementia (a condition resulting in impairment of two brain functions such as memory loss and judgements), anxiety, personal history of malignant breast cancer (a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body), and secondary malignant cancer of lung, liver, and bile ducts (a disease in which the body's cells grow uncontrollably and had started from somewhere else in the body and has spread to lung, liver, and bile ducts).
Review of undated care plan showed:
-He/She was at risk for pressure ulcers and skin breakdown;
-Reposition him/her every 2 hours and as needed;
-Encourage him/her to shift weight while sitting up in chair;
-He/She needed two persons to assist with repositioning to avoid skin friction and shearing.
Review of physician's orders, dated March 2023, showed:
-Order started 3/6/24, apply triple antibiotic ointment to right hip every shift shearing to zinc oxide to bottom with every bowel movement and as needed;
Observation on 3/14/24 at 7:57 A.M. showed resident up in broda chair in dining room.
Observation on 3/14/24 at 10:00 A.M. showed resident remained up in his/her broda chair in foyer across from nurse's station, he/she had not been repositioned.
Observation on 3/14/24 at 10:54 A.M. showed resident remained in sitting area across from nurse's station. He/She had not been changed ore repositioned since getting into broda chair at breakfast.
Observation on 3/14/24 at 11:10 A.M. showed resident taken to room to be provided incontinent care and repositioning, over three hours after observation started at 7:57 A.M.
During an interview on 3/14/24 at 10:15 A.M. CNA B said:
-He/She did not do repositioning or cares since breakfast on this resident;
2. Review of Resident #18's Annual MDS, dated [DATE], showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 12, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident had moderately impaired cognition.
-He/She had clear speech;
-He/She was dependent for oral care, toileting, bathing, upper and lower body dressing, putting and taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting, and transfers;
-He/She used wheelchair for mobility;
-He/She was always incontinent of bowel and bladder;
-Diagnoses included Parkinson's disease (a condition of central nervous system that affects movement including tremors), renal insufficiency ( a condition in which the kidneys lose the ability to remove waste and balance fluids), dementia (a condition characterized by impairment of at least two brain functions, such as memory loss and judgement), difficulty in walking, and agoraphobia with panic disorder (a condition where patients avoid situations or places in where they fear being embarrassed or being unable to escape).
Review of care plan, undated showed:
-He/She had potential for skin breakdown;
-Provide me with incontinent care after each episode;
-Keep linens and clothing free of wrinkles as possible;
-Provide me with pressure reduction cushion;
-Turn and reposition him/her according to his/her turn schedule
Observation on 3/14/24 at 7:57 A.M. showed the resident was seated at table in dining room.
Observation on 3/14/24 at 10:00 A.M. showed the resident remained seated in his/her wheelchair seated across from the nurse's station. He/She had not been out of wheelchair.
Observation on 3/14/24 at 10:24 A.M. showed administrator inquiring if the residents wanted to go watch bowling. The resident was asked by CNA B if he/she wanted to go watch and he/she agreed.
Observation on 3/14/24 at 10:54 A.M. showed the resident in dining room and he/she had not been provided cares or repositioning since prior to breakfast.
During an interview on 3/14/24 at 10:15 A.M. CNA B said he/she had not repositioned the resident since getting him/her out of bed this morning before breakfast.
3. Review of the Resident #37's Quarterly MDS, dated [DATE], showed:
- The resident had long and short term memory problems;
- The resident was independent with eating;
- Substantial to moderate assistance with dressing the lower extremities, personal hygiene and transfers;
- Always incontinent of bowel and bladder;
- Diagnoses included cancer, dementia, anxiety and depression.
Review of care plan, undated, showed:
-He/She was at risk for pressure ulcers due to his/her disease processes
-Reposition him/her every 2 hours and as needed;
-Place a pressure-reducing device in wheelchair;
-Encourage him/her to weight shift while sitting up in chair;
-Assist with two staff and mechanical lift for transfers;
Observation on 3/14/24 at 7:57 A.M. showed the resident was in dining room in broda chair waiting for breakfast service.
Observation on 3/14/24 at 10:00 showed the resident remained in broda chair sitting across from nurse's station. He/She had not been provided repositioning.
Observation on 3/14/24 at 10:24 A.M. showed the Administrator and CNA B inquired if resident wanted to activity of bowling in the dining room. Resident shook head and said he/she did not want to go. Resident remained in sitting area across from nurses station.
Observation on 3/14/24 at 10:54 A.M. showed the resident had not been provided incontinent care or repositioned since prior to breakfast.
Observation on 3/14/24 at 11:10 A.M. showed the resident taken to room and laid down and provided cares.
During an interview on 3/14/24 at 10:15 A.M. CNA B said he/she had not been repositioned or provided care since breakfast.
4. During an interview on 3/14/24 at 10:15 A.M. CNA B said:
-He/She would like to lay everyone down and provide cares between breakfast and lunch;
-He/She started getting residents out of bed at 6:00 A.M., by starting at end of hallway and working way back down;
-All residents were soaked upon arrival to shift today and he/she took look longer getting residents up and out of bed this morning took longer than normal as no residents had been gotten out of bed when he/she arrived for shift;
-He/She had to wait to provide repositioning and incontinent cares to residents as one of the aides must stay in the dining room to assist residents until all residents are done;
-All residents on the 200 hallway were two person transfers so he/she could not lay residents down on his/her own.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said he/she expected the residents to be offered repositioning and incontinent care as often as needed and checked every thirty minutes.
During an interview on 3/15/24 at 7:35 P.M., the Regional Director of Nursing said he/she expected residents to be provided repositioning and incontinent care not less than every two hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected multiple residents
Based on observations, interview, and record review, the facility failed to ensure nurse aides (NA) were certified within four months and failed to ensure nurse aides were in a state-approved training...
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Based on observations, interview, and record review, the facility failed to ensure nurse aides (NA) were certified within four months and failed to ensure nurse aides were in a state-approved training program. Facility census was 40.
Review of the facility's policy for nurse aide qualifications and training program, revised August, 2022 showed, in part:
- Nurse aides must undergo a state-approved training program;
- The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem or otherwise, unless that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state.
1. Review of the NA employee list showed:
- NA D employed since 9/5/23;
- NA F employed since 7/26/23.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said:
- The NAs have to be through the training by the end of their four month hire date;
- They will send the NAs to their sister facility for training.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than five percent (5%). Facility staff made seven...
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Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than five percent (5%). Facility staff made seven medication errors out of 25 opportunities for error, resulting in a medication error rate of 28%. This affected four of 12 sampled residents, (Resident #6, Resident #9, Resident #15 and Resident #17). The facility census was 40.
Review of the facility's policy for administering medications, revised April 2019, showed, in part:
- Medications are administered in a safe and timely manner, and as prescribed;
- Medications are administered in accordance with prescriber orders, including any required time frame;
- Medications are administered within one hour of their prescribed tie, unless otherwise specified (for example, before and after meal orders);
- The individual administering the medications checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication;
- Staff follows established facility infection control procedures (e.g. hand washing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable.
1. Review of Resident #6's physician order sheet (POS), dated March 2024, showed:
- Start date: 9/8/22 - Tylenol 500 milligrams (mg.) two tabs daily for pain. Not to exceed three grams in 24 hours;
- Start date: Calcium 500 mg. with Vitamin D 400 international units (IU) one three times daily for supplement.
The facility did not provide the resident's complete medication administration records (MAR).
Observation on 3/13/24 at 7:24 A.M., showed:
- Certified Medication Technician (CMT) A placed Tylenol 325 mg. two tabs in a clear medication cup;
- CMT A placed Calcium 500 mg. in the clear medication cup;
- At 7:27 A.M., CMT A administered the medication to the resident.
2. Review of Resident #15's POS, dated March 2024 showed;
- Start date: 10/31/22 - Calcium 500 mg with Vitamin D 5 micrograms (mcg.) two tabs twice daily for supplement.
Review of the resident's MAR, dated March 2024 showed:
- Calcium 500 mg with Vitamin D 5 micrograms (mcg.) two tabs twice daily for supplement.
Observation on 3/13/24 7:45 A.M., showed:
- CMT A placed Calcium 500 mg. in the clear medication cup;
- At 7:49 A.M., the resident was asleep but woke up to take his/her medication then laid back down and went to sleep.
During an interview on 3/14/24 at 1:41 P.M., CMT A said:
- If the order was for Tylenol 500 mg., then that is what he/she should have administered;
- They have two different bottles of Calcium, one plain and one with Vitamin D. If the order said with Vitamin D, that is what he/she should have administered.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said:
- It would not be appropriate to administer Tylenol 325 mg. instead of the Tylenol 500 mg.;
- If the order was Calcium with Vitamin D, then that is what the staff should have administered.
3. Review of the facility's undated policy for oral and nasal inhalation administration, showed, in part:
- Have the resident gently blow their nose to clear the nostrils;
- Shake the inhaler well and remove cap from nozzle;
- Hold the inhaler in upright position between second and index finger and thumb places on bottom of canister;
- With resident's head tilted back, carefully insert nozzle into one nostril and close the other nostril with one finger;
- While resident gently inhales through open nostril, press medication canister up with the thumb;
- Instruct resident to hold breath, and then breathe out thorough their mouth.
Review of the manufacturer's guidelines for Flonase Nasal Spray, (used to treat allergies) revised February 2022, showed, in part:
- Shake the bottle gently before use;
- Blow your nose to clear your nostrils;
- Close one nostril. Tilt your head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the other nostril;
- Start to breathe in through your nose, and while breathing in, press firmly and quickly down once on the applicator to release the spray;
- Repeat in the other nostril.
Review of Resident 9's POS, dated March 2024 showed:
- Start date: 1/11/24 - Flonase nasal spray, one spray in each nare twice daily for allergies;
- The order did not specify how many mg.
The facility did not provide the resident's complete MARs.
Observation on 3/13/24 at 7:52 A.M., showed:
- CMT A did not give the resident any instructions and gave him/her the nasal spray;
- The resident gave him/herself one spray in each nostril;
- The resident did not shake the bottle, did not blow his/her nose and did not close one side of his/her nostril.
4. Review of the facility's administering medications through a metered dose inhaler, revised October, 2010 showed, in part:
- The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications;
- Explain the procedure to the resident;
- Administer the medication: shake the inhaler gently to mix the medication with aerosol propellant. Ask the resident to inhale and exhale deeply for a few breath cycles. On the last cycle, instruct the resident to exhale deeply. Place the mouthpiece in the mouth and instruct resident to close his/her lips to form a seal around the mouthpiece. Firmly depress the mouthpiece against the medication canister to administer medication. Instruct the resident to inhale deeply and hold for several seconds;
- Allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications;
- Rinse the mouthpiece with warm water to remove medication residue.
Review of Resident #17's POS, dated March 2024 showed:
- Start date: 2/1/24 - Spiriva 18 mcg. one cap inhaled daily using two puffs for COPD;
- Start date: 2/1/24 - Advair Diskus (Fluticasone propionate and Salmeterol) 250-50 mcg. powder, inhale twice daily for chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Rinse mouth after use.
The facility did not provide the resident's complete MARs.
Observation on 3/13/24 at 8:08 A.M., showed:
- The resident sat at the table in the dining room;
- CMT A did not give the resident any instructions and handed the Flonase inhaler to the resident who gave him/herself one inhalation and did not rinse his/her mouth, did not wait and immediately used the Spiriva and gave him/herself two inhalations.
During an interview on 3/14/24 at 1:41 P.M., CMT A said:
- He/she should have followed the manufacturer's guidelines for the Nasal Spray (shake the bottle, blow his/her nose, close one side of the nostril);
- He/she should have given the residents instructions on how to use the nasal sprays and inhalers;
- Did not think you had to wait between two different inhalers;
- Should have made sure the resident rinsed his/her mouth with water and spit it out and not swallow it.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said:
- Staff should follow the manufacturer's guidelines for the administration of Flonase;
- The staff should give the resident instructions on how to use the nasal sprays and the inhalers;
- Staff should make sure if the order said to rinse his/her mouth out with water and spit, and not swallow it, then that is what the staff should do;
- The Regional Nurse said she thought you should wait five minutes or the safer route of ten minutes between inhalers. The Administrator thought staff should wait five minutes between the inhalers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #11's Quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, show...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #11's Quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 13, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact.
-He/She had clear speech, was able to make self understood and understand others;
-He/She used walker and wheelchair for mobility;
-He/She required set up or clean up assistance with eating, oral hygiene, toileting, bathing, upper and lower body dressing, putting and taking off footwear, rolling left to right, sitting to lying, lying to sitting, sitting to standing, and with chair to bed, toilet, and tub transfers.
-Diagnoses included generalized muscle weakness, tremor (a condition causing involuntary shaking or movement), difficulty in walking, and frailty (an age-related physical debility including weakness and fatigue and reduced tolerance for medical and surgical interventions).
Observation on 3/12/24 at 12:01 P.M. showed CMT A handed medications to resident. CMT A did not watch resident take medications and medications were placed sitting on the table.
Observation on 3/12/24 at 12:07 P.M. showed resident's medications remain in cup on the dining room table in front of resident.
Observation on 3/13/24 at 12:08 P.M. showed resident had pills in front of him/her at the dining table. Three pills are observed in cup including a yellow pill and two white round pills. CMT A observed passing medications.
Observation on 3/13/24 at 12:20 P.M. showed LPN A came over to resident's table and spoke to resident. Resident observed taking pills from table that were sat in front of him/her. LPN A then grabbed empty pill cup to discard.
During an interview on 3/13/24 at 12:21 P.M., CMT A said:
-Resident can self administer his/her medications;
-He/She normally left residents medications on the table because resident wanted them there as he/she wanted to take medications with his/her food;
-If he/she told resident to take his/her medications the resident would become upset with him/her.
During an interview on 3/13/24 at 12:23 P.M., LPN A said:
-Resident cannot self-administer his/her own medications;
-It was not standard of practice to leave resident's medications sitting on the table in the dining room;
-He/She saw medications sitting on table during lunch and so he/she went over and asked resident to take his/her medications and then addressed the issue with CMT A;
-Resident had cream or powder that he/she can self-administer at bedside but does not self-administer any other medications.
Based on observations, interviews and record review, the facility failed to ensure staff did not leave medications unattended in the resident's rooms and in the dining room, which affected three of 12 sampled residents, (Resident #7, Resident #9 and Resident #11). The facility census was 40.
Review of the facility's policy for administering medications, revised April 2019, showed, in part:
- Medications are administered in a safe and timely manner, and as prescribed;
- Medications are administered in accordance with prescriber orders, including any required time frame;
- Medications are administered within one hour of their prescribed tie, unless otherwise specified (for example, before and after meal orders);
- The individual administering the medications checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication;
- Staff follows established facility infection control procedures (e.g. hand washing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable.
1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/24 showed:
- Cognitive skills intact;
- Independent with eating, personal hygiene, toilet use, dressing and transfers;
- Diagnoses included high blood pressure, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood flow to the kidneys caused by renal artery disease), arthritis, anxiety and depression.
Review of the resident's physician order sheet (POS), dated March 2024 showed:
Start date: 4/15/23 - Allopurinol 300 milligrams (mg.) one tab with food daily for gout.
Review of the resident's medication administration record (MAR), dated March 2024 showed, Allopurinol 300 mg. one tab with food daily for gout.
Observation on 3/13/24 at 7:38 A.M., showed Certified Medication Technician (CMT) A left the medicine cup with the resident's medications on the resident's over the bed table because the resident was sleeping.
During an interview on 3/13/24 at 7:38 A.M., CMT A said:
- He/she left the medicine in the resident's room because the resident was still asleep but he/she would want them when he/she woke up;
- It was alright to do that because the room mate did not walk and no one would enter the room.
2. Review of Resident #9's Annual MDS, dated [DATE] showed:
- Cognitive skills moderately impaired;
- Independent with eating, transfers and toilet use;
- Always continent of bowel and bladder;
- Diagnoses included diabetes mellitus, seizure disorder, bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).
Observation and interview on 3/12/24 at 10:09 A.M., showed:
- The resident had a clear plastic medication cup with at least 12 pills in the cup and bottle of Flonase nasal spray on the resident's over the bed table;
- The resident was asleep but woke up and said the staff leave his/her medications at times.
During an interview on 3/14/24 at 1:41 P.M., CMT A said:
- He/she should not leave the medications at bedside;
- He/she should have followed up to see if the resident had taken his/her pills.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said the staff should not leave the resident's medication at their bedside.
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 and interviews, the facility failed to ensure staff served food to the residents that was palatable, attrac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to five of twelve sampled residents (Resident #192, #36, #7, #9, and #11) The facility had a census of 40.
Review of facility policy, serving temperature for hot and cold foods, dated 2016, showed:
-Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking or cooling of foods. These are minimum serving/holding temperatures and may vary based on state regulations. Hot foods served at higher temperatures, based on resident preference, must be done cautiously because foods served too hot may potentially decrease food quality and possibly contribute to resident burns.
-Meats and casseroles, vegetables, potatoes, gravy, soups 135 degrees Fahernheit (F) to 170 degrees F;
-Hot beverages: follow facility guidelines
-Cold beverages, fruits, desserts, salads, and dairy: 41 degrees F or below
-Cereal: 135 degrees F to 160 degrees F;
-The cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. Food temperatures will be recorded.
-Plates or trays prepared first are served first. No more than four plates or trays are prepared at once.
Review of facility policy, monitoring food temperatures for meal service, dated 2016, showed:
-Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures.
-If the serving/holding temperature of hot food item is not 135 degrees F or higher when checked prior to meal service, the item will be reheated to at least 165 degrees F.
-Meals served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trapys at point of service are preferred to be at 120 degrees F or greater to promote palatability for the resident.
-Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below.
-The temperature for each food item will be recorded on the food temperature log. Foods that required a corrective action; will have the new temperature recorded with a circle around it next to the original temperature.
Review of facility policy, sanitation guidelines, dated 2016, showed:
-All hot food prepared for the steam table will have the internal cooking temperature tested before removing from the oven to ensure that the product was reached the minimum internal cooking temperature.
-All foods, both hot and cold, that are potentially hazardous food (PFH) or time/temperature control for safety food, will have the food temperature taken before the start of meal service and every one-half hour thereafter to ensure the maintenance of food temperatures on serving equipment during the entire length of meal service. All hot foods are kept on a steam table and cold foods are kept in a refrigerated unit or on ice while being held for service.
1. Review of Resident #192's facility face sheet, dated 3/15/24 showed:
-He/She was admitted [DATE];
-He/She was own responsible party;
-Diagnosis included sepsis (A life threatening complication of an infection), bacteremia (a condition with the presence of viable bacteria circulating in blood), extranodal non-hodgkin's lymphoma (a cancer that starts in lymphatic system), and epilepsy (a brain disorder that causes recurring, unprovoked seizures).
During an interview on 3/12/24 at 12:26 P.M. resident said food did not come out hot. He/She had been eating in room at end of hall and by the time food got to him/her the food was usually not warm. The food did not taste great.
2. Review of Resident #36's Quarterly MDS, dated [DATE] showed:
- Cognitive skills intact;
- Independent with eating, dressing, personal hygiene, toilet use and transfers;
- Always continent of bowel and bladder;
- Diagnoses included stroke, hemiplegia (paralysis affecting one side of the body), diabetes mellitus, anxiety and depression.
During an interview on 3/12/24 at 9:40 A.M., the resident said the food was terrible. The vegetables were overcooked and were like mush.
3. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/24 showed:
- Cognitive skills intact;
- Independent with eating, personal hygiene, toilet use, dressing and transfers;
- Diagnoses included high blood pressure, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood flow to the kidneys caused by renal artery disease), arthritis, anxiety and depression.
During an interview on 3/12/24 at 2:03 P.M., resident said food was usually cold when he/she got it in dining room.
4. Review of Resident #9's Annual MDS, dated [DATE] showed:
- Cognitive skills moderately impaired;
- Independent with eating, transfers and toilet use;
- Always continent of bowel and bladder;
- Diagnoses included diabetes mellitus, seizure disorder, bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).
Observation on 3/14/24 at 12:12 showed resident sent his/her plate back as he/she did not like the noodles.
During an interview on 3/14/24 at 12:23 P.M. resident said the noodles were mushy and cold.
5. Review of Resident #11's quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed:
-He/She had a Brief Interview Mental Status (BIMS) score of 13, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact.
-He/She had clear speech, was able to make self understood and understand others;
-He/She used walker and wheelchair for mobility;
-He/She required set up or clean up assistance with eating, oral hygiene, toileting, bathing, upper and lower body dressing, putting and taking off footwear, rolling left to right, sitting to lying, lying to sitting, sitting to standing, and with chair to bed, toilet, and tub transfers.
-Diagnoses included generalized muscle weakness, tremor (a condition causing involuntary shaking or movement), difficulty in walking, and frailty (an age-related physical debility including weakness and fatigue and reduced tolerance for medical and surgical interventions).
During an interview on 3/14/24 at 12:47 P.M. the resident said he/she did not have enough sauce over his/her noodles at lunch.
6. Review of menu on 3/14/24 showed:
-Chicken alfredo over fettuccini, garnish with parmesan cheese;
-To serve place 6oz spdl of chicken alfredo over 4oz spoodle of pasta. Garnish with parmesan and parsley;
-Final cooking temperature greater than 165 degrees Fahernheit or above held for 15 seconds;
-Maintain 135 degrees Fahernheit or above;
Observation on 3/14/24 at 10:56 A.M. of lunch preparation showed the noodles were placed on the steam table.
Observation on 3/14/24 at 11:24 A.M. showed [NAME] A removed lids from food on steam table. He/She did not temperature check foods. He/She began dishing out first plate for meal service.
During an interview on 3/14/24 at 11:28 A.M., Dietary Manager said:
-Food temperatures should be recorded at time of food preparation, before it went on steam table, and before it was served.
During an interview on 3/14/24 at 11:35 A.M., [NAME] A said:
-He/She temperature checked food after it came off the stove and before he/she put it on the steam table;
-He/She did temperature check food as it was cooking but did not write it down on log yet.
Observation on 3/14/24 at 12:04 P.M. showed [NAME] A added only half of scoop of alfredo and chicken added with 6oz spoodle;
Observation on 3/14/24 at 12:08 P.M. showed [NAME] A added only half a scoof of alfredo and chicken over noodles with the 6oz spoodle.
Observation on 3/14/24 at 12:16 P.M. showed [NAME] A did not give full scoop of chicken and alfredo sauce over noodles with spoodle.
Observation on 3/14/24 at 12:33 P.M. showed the food had not been temperature checked since observation began at 10:56 A.M.
Observation of test tray on 3/14/24 at 12:36 P.M. showed fettucine with sauce over top of it was cold, squishy, and below appropriate hot food serving temperature at 113.1 degrees.
During an interview on 3/14/24 at 1:37 P.M., Dietary Aide A said:
-Food should be temperature checked before it is placed on steam table and before he/she started serving food;
-He/She documented food temperatures in log.
During an interview on 3/14/24 at 1:49 P.M., [NAME] A said:
-Food temperatures should be taken after food was heated up on stove and after food was placed on steam table;
-He/She did not temperature check the food before serving from steam table on 3/14/24.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-He/She expected the cook to temperature check food when it was being cooked, when it was held on steam table, and before it was served.
During an interview on 3/15/24 at 4:05 P.M., the Dietary Aide B said:
-He/She had worked in kitchen for one year;
-He/She was trained on how to clean the dishwasher, how to temperature check foods, and how to sanitize items;
During an interview on 3/15/24 at 4:11 P.M., Dietary Aide C said:
-He/She was not aware of residents complaining of hot food being served cold.
During an interview on 3/15/24 at 4:16 P.M., [NAME] B said:
-Food temperatures should be checked before he/she took food out of the stove;
-Food temperatures should be documented in the temperature logbook located in dietary office;
-He/She temperature checked food on serving line after he/she served all food to residents.
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
-Food should be temperature checked before it was served.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable infection prevention and control pra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable infection prevention and control practices to help prevent the development and the transmission of communicable diseases as well as infections, when staff failed to administer medication in a safe manner, when staff used their bare fingers to administer medications to one resident (Resident #15), and when staff failed to wash or sanitize their hands and change gloves between dirty and clean tasks. Additionally, staff failed to follow infection prevention measures when staff placed soiled linens directly on the floor when providing incontinent care for one resident (Resident #37) and when facility staff failed to follow their Employee Screening for Tuberculosis policy for three of 10 sampled new hires. The facility census was 40.
Review of the facility's policy for administering medications, revised April 2019, showed, in part:
- Medications are administered in a safe and timely manner, and as prescribed;
- Medications are administered in accordance with prescriber orders, including any required time frame;
- Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders);
- The individual administering the medications checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication;
- Staff follows established facility infection control procedures (e.g. hand washing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable.
1. Review of Resident #15's Annual MDS, dated [DATE] showed:
- Cognitive skills severely impaired;
- Independent with eating and transfers;
- Partial/Moderate assistance with toilet use and personal hygiene;
- Supervision or touching assistance with dressing;
- Diagnoses included coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart), high blood pressure, diabetes mellitus, dementia, traumatic brain injury (TBI, a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury), depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing).
Review of the resident's physician's order sheet (POS), dated March 2024 showed medication start date: 1/9/18 - Enteric coated aspirin (ECASA) one tab daily with food for prophylaxis.
Observation on 3/13/24 at 7:45 A.M., showed, without sanatizing or washing his/her hands, Certified Medication Technician (CMT) A dumped a handful of the ECASA tabs in the lid of the bottle and used his/her bare fingers and picked one up and placed in the clear plastic medication cup and administered the medications to the resident.
2. Review of Resident #37's quarterly MDS, dated [DATE] showed:
- Long and short term memory problems;
- Independent eating;
- Supervision or touch assistance with oral hygiene;
- Partial to moderate assistance with toilet use, showers and dressing the upper body;
- Substantial to moderate assistance with dressing the lower extremities, personal hygiene and transfers;
- Always incontinent of bowel and bladder;
- Diagnoses included cancer, other fracture, dementia, anxiety and depression.
Review of the resident's undated care plan showed:
- The resident was frequently incontinent of urine and bowel;
- Staff are directed to assist with perineal cleansing as needed.
Observation on 3/13/24 at 6:49 A.M., showed:
- CNA B and Nurse Aide (NA) A provided incontinent care to the resident;
- CNA B cleaned fecal material from the resident, removed his/her gloves, did not wash his/her hand and applied new gloves and continued to provide incontinent care with fecal material noted. CNA B removed gloves again, did not wash his/her hands and applied new gloves;
- NA A removed the soiled linens and placed them directly on the floor;
- After CNA B and NA A finished providing incontinent care, they removed their gloves, did not wash his/her hands and applied new gloves then used the mechanical lift to transfer the resident from the bed to the Broda chair (type of reclining geri chair);
- Both removed gloves and washed hands.
During an interview on 3/14/24 at 1:34 P.M., CNA B said:
- Should have washed his/her hands between dirty and clean tasks;
- Should wash or sanitize hands when cleaning fecal material;
- Should not have placed the soiled linens directly on the floor, they should have been placed in a bag.
During an interview on 3/15/24 at 9:49 A.M., NA A said:
- He/She should have removed gloves and washed his/her hands after being soiled, before and after cares, when cleaning fecal material and between glove changes;
- The soiled linens should not have been placed on the floor.
During an interview on 3/15/24 at 7:35 P.M., the Administrator and the Regional Nurse said:
- Staff should remove their gloves and wash their hands when cleaning fecal material;
- The Regional Nurse said staff should wash their hands when they enter the resident's room, when visibly soiled and anytime between clean and dirty procedures;
- Staff should not place soiled linens directly on the floor;
Review of the facility's policy, titled Employee Screening for Tuberculosis (a contagious infection that affects the lungs) revised March 2021, showed:
-All employees are screened for latent tuberculosis (TB) and active TB using a tuberculin skin test (TST) or interferon gamma release assay (a blood test used to see whether a person has been infected with the bacteria causing TB) prior to beginning employment.
3. Review of the facility's Hand Hygiene Policy revised October 2023, showed:
-Hand Hygiene is indicated:
o Between clean and dirty tasks;
o After contact with bodily fluids;
o After glove removal.
1. Review of [NAME] C's personnel file showed:
- A hire date of 1/3/24;
-No documentation staff conducted a TB test prior to beginning employment was found.
2. Review of Nures Aide F's personnel file showed:
- A hire date of 7/26/23;
-No documentation staff conducted a TB test prior to beginning employment was found.
3. Review of Certified Medication Technician (CMT) B's personnel file showed:
-A hire date of 12/15/23;
-No documentation staff conducted a TB test prior to beginning employment was found.
During an interview on 3/15/24 at 7:32 P.M., the Administrator and the Regional Nurse said:
-Employee TB tests should be administered before they go to the floor or do any kind of work;
-This should be documented in the employee's personnel file.
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 observations and interviews, the facility failed to hire or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 40.
The ...
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Based on observations and interviews, the facility failed to hire or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 40.
The facility provided an undocumented time frame for when the facility had a DON working which showed:
- A DON worked from 1/23/23 - 3/5/23;
- A DON worked from 3/6/23 - 6/20/23;
- A DON worked from 6/21/23 - 9/15/23;
- A DON worked from 9/16/23 - 1/16/24;
- A DON worked from 2/9/24 - 3/9/24.
Observations from 3/12/24 through 3/15/24 and on 3/18/24, at various times showed the facility had charge nurses (CN) available, but did not have a DON.
During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said:
- He/she did not know who the DON was;
- He/she was the ADON but did not think they had a DON.
During the entrance conference on 3/12/24 at 8:35 A.M., the Administrator said:
- They had a DON but he/she quit on 3/9/24;
- They were in the process of finding another DON.
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, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to clean an...
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Based on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to clean and sanitize all areas of the kitchen, maintain a thermometer in the chest freezer, compete proper hand washing techniques, maintain a lid on trash cans, temperature check food before it was served to residents, utilize and ensure proper parts per million (PPM) of sanitizer solution, discard expired food, ensure all employees wear hair and beard nets, invert clean pitchers for storage, label and date all foods. This had the potential to impact all residents in the facility. The facility census was 40 residents.
1. Review of facility policy, sanitation of dining and food service areas:
-Dining service staff will uphold sanitation of the dining areas according to a thorough written schedule.
-Dining services manager will record necessary cleaning and sanitation tasks for department
-Tasks will be designated to specific departmental positions (cleaning schedule forms).
-All staff will be trained on frequency of cleaning.
-A cleaning schedule will be posted for all cleaning tasks. Staff will initial the tasks as they are completed.
-Staff will be held responsible for all cleaning tasks.
Review of facility policy, cleaning rotation, dated 2016, showed:
-Equipment and utensils will be cleaned according to following guidelines or manufacturer's instructions.
-Cleaned daily: Kitchen floors;
-Cleaned weekly: drawers;
-Cleaned monthly: refrigerators, freezers, ingredient bins, walls;
-Cleaned annually: ceilings.
Review of facility policy, cleaning instructions showed:
-Kitchen floors will be swept and cleaned after each meal.
-Floors will be washed daily, using hot water and detergent.
-At least once a month, large appliances will be moved to clean behind and underneath them.
Review of facility policy, cleaning instructions showed for the reach in refrigerator and freezer, dated 2016 showed:
-Reach in refrigerator and freezer will be cleaned and sanitized on a regular basis.
-Clean up spills and wipe down outside of refrigerator and freezer with a clean cloth dipped in sanitizing solution as needed.
-Based on cleaning schedule remove all food, beverages, shelves in preparation of thorough cleaning.
Observation on 3/12/24 at 8:20 A.M. showed:
-Two gallons of whole milk in the refrigerator had a brown substance spilled on them;
-Bottom of the cooler had spilled food strewn across it;
-Freezer unit had frozen broccoli pieces laying across the bottom and a white powder substance;
-Light sconces were caked in dirt;
-Food particles in the bottom of the white plastic utensils bin where serving spoons were stored;
-Pancake syrup was on the outside of the pancake syrup container.
Observation on 3/14/24 at 11:44 A.M. showed lettuce was stuck to the edge of the clean dish rest area.
During an interview on 3/14/24 at 1:37 P.M., Dietary Aide A said:
-Kitchen cleaning routine included cleaning it everyday.
During an interview on 3/14/24 at 1:49 P.M., [NAME] A said:
-Kitchen cleaning routine expectation was that he/she cleaned his/her side of the kitchen by wiping up everything with sanitization solution;
-Facility staff deep cleaned when they had down time;
-Deep cleaning of kitchen did not occur very often.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-The refrigerator and freezer were cleaned once a month;
-He/She expected food to be rotated when the food truck made a delivery;
-He/She expected dietary staff to wipe down items after use and clean up spills immediately;
-He/She expected staff to sweep and mop every night;
-He/She had not moved the freezer to clean underneath since working in kitchen;
-He/She expected the kitchen staff to work as a team to clean the kitchen.
During an interview on 3/15/24 at 4:05 P.M., the Dietary Aide B said:
-He/She completed dishes and cleaned up the dining room after meals;
-He/She cleaned the dietary aide side of the kitchen;
-He/She did not have a list to follow as part of cleaning routine of kitchen;
-He/She did not clean out the refrigerator or freezers;
-He/She cleaned the air fryer and microwave and wiped down counters on his/her side of kitchen.
During an interview on 3/15/24 at 4:11 P.M., Dietary Aide C said:
-Facility had no checklist for cleaning the dining room, he/she had the routine memorized;
-He/She primarily did dishes while working.
During an interview on 3/15/24 at 4:16 P.M., [NAME] B said:
-Refrigerator should be cleaned immediately after a spill;
-He/She was supposed to clean the stove, grill, grease trap and mop his/her side of kitchen, take out trash, and assist the dietary aides.
2. Review of facility policy, cleaning instructions: Trash barrels and trash area, dated 2016, showed:
-Trash barrels were supposed to be covered with lid.
Observation on 3/12/24 at 8:20 A.M. showed:
-The trash can near the three compartment sink had no lid.
Observation on 3/12/24 at 8:40 A.M., showed:
-The trash can in dishwashing room had no lid on it.
During an interview on 3/14/24 at 1:37 P.M., Dietary Aide A said:
-Trash cans should have lids on them;
-Facility staff did not have the lids on the trash today because as there were no lids for the trash cans. - The Administrator had identified this as an issue and kitchen was in process of finding lids to purchase or obtaining new trash cans.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-Trash cans in kitchen did not have lids and have not had lids in over two years he/she had been working in kitchen;
-Trash cans should have lids on them.
During an interview on 3/14/24 at 1:49 P.M., [NAME] A said:
-Trash cans should be covered with lids;
-The facility did not have trash cans with lids.
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
-He/She expected trash cans to have lids.
3. Review of facility policy, sanitizing equipment and food contact services, dated 2016, showed:
-Employees shall sanitize equipment and food contact surfaces utilizing proper sanitizing solution;
-Sanitizing solutions are changed in accordance with manufacturer instructions or when they become visibly soiled. In general, each shift should prepare fresh solutions.
Review of facility policy, sanitizing solution, dated 2016, showed:
-If a dispensing system is used it will be tested daily to ensure solution is dispensed at the appropriate concentration level.
Observation on 3/12/24 at 8:20 A.M., showed:
-No sanitizer buckets were available or in use;
-There were three buckets observed and all three were empty, one bucket was on a shelf under the preparation table, one was on a wire dish rack, and one was in the dining room by the sink.
Observation on 3/12/24 at 8:38 A.M. showed:
-Dietary Aide A filled the sanitizer bucket up at three compartment sink;
-Sanitizer test strip dipped by Dietary Aide A into the bucket showed a reading of 300 PPM.
Observation on 3/14/24 at 11:03 A.M. showed a sanitizer bucket had water in it and was located on right side of preparation table.
Observation on 3/14/24 at 11:12 A.M. showed [NAME] A used a wash cloth out of the sanitizer bucket and wiped off the preparation table.
Observation on 3/14/24 at 11:16 A.M. showed [NAME] A completed test strip a red sanitizer bucket. The test strip showed bright green at 400 PPM, indicating the sanitizer solution was too high.
During an interview on 3/14/24 at 1:37 P.M., Dietary Aide A said:
-Everyone was responsible for checking sanitation buckets;
-Sanitation buckets should be changed every two hours.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-Sanitizer buckets should be changed every two hours;
-He/She did not have staff log for staff to document sanitizer bucket checks for proper PPM.
During an interview on 3/15/24 at 4:05 P.M., the Dietary Aide B said:
-Sanitizer buckets should be changed every two hours;
-He/She did not know how to check the sanitizer buckets for proper PPM;
-There was not a sanitizer bucket log.
During an interview on 3/15/24 at 4:16 P.M., [NAME] B said:
-He/She switched out sanitizer bucket at start of shift;
-He/She changed sanitizer bucket twice during his/her shift.
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
-He/She expected sanitizer buckets to be ready for use at anytime in kitchen.
During an interview on 3/15/24 at 7:35 P.M., Regional DON said:
-He/She expected sanitizer buckets to be set up prior to kitchen use.
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
-Bleach solution should be at a concentration of greater than or equal to 50 to 100 PPM or in accordance with label instructions for other types of sanitizers.
-This solution can be used for sanitizing equipment and food contact surfaces. All rags used for sanitizing must be kept in sanitizing solution when not in use.
4. Review of facility policy, Dishwashing: Machine Operation, dated 2016, showed:
-The dining services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food.
-Check dishwashing machine each morning before first set of dishes are to be washed. This is before breakfast meal and again in the afternoon or generally before the supper meal. If dishwashing machine had not be used for several hours, it is recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. If chemical sanitizer is used, check the concentration using the correct test tape for type of sanitizer in use. If not at the correct chemical sanitizing concentration, do not proceed to wash dishes.
-Check the dishwashing machine for cleanliness before the start of each meal. Sanitize the clean work table before starting dishes at each meal. Clean bottom drain cover as necessary during dishwashing to ensure food debris does not build up. Wipe down the dishwashing machine and clean per equipment cleaning procedure at end of each work day. Remove any built up debris, lime, or scale as necessary or generally complete a thorough deliming per cleaning schedule or one time weekly.
Observation of dishwasher sanitizer machine log showed:
-No entry on 3/11/24 for PM;
-No entry for 3/12/24 for AM.
Observation on 3/12/24 at 8:41 A.M. showed:
-Dietary Aide A ran test strip of dishwasher which showed white or 0 PPM of sanitizer solution.
During an interview on 3/12/24 at 8:41 A.M., Dietary Aide A said:
-Sanitation company fixed the dishwasher recently because someone altered the dishwasher and it was not working properly. The dishwasher was fixed.
-He/She said he had ran test strip earlier in the day and the dishwasher solution tested at appropriate PPM.
Observation on 3/12/24 at 8:44 A.M. showed Dietary Aide hit prime button on dishwasher and ran dishwasher a second time. Dishwasher strip showed 200 PPM.
Observation on 3/14/24 at 11:40 A.M. showed Dietary Aide A ran rest strip and read purple or 200 PPM.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-He/She expected the dishwasher to be tested before every shift;
-He/She had an in-service completed on 3/7/24 on using and operating the dishwasher.
During an interview on 3/15/24 at 4:05 P.M., the Dietary Aide B said:
-He/She did use sanitization strips to check dishwasher;
-He/She check dishwasher PPM after every meal;
5. Observation on 3/12/24 at 8:20 A.M. showed:
-Pitchers top shelf of wire dish rack were stored upright, allowing tops open and exposed to particles.
Observation on 3/12/24 at 8:38 A.M. showed:
-Small dessert plates and bowls were stored upright on dish rack.
Observation on 3/14/24 at 10:56 A.M. showed:
-Drink pitchers on top rack of dish rack are upright with openings exposed to peeling paint from ceiling.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-The pitchers currently were stored upright which was incorrect.
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
-Clean pitchers should be stored down so their tops were not open to ceiling.
6. Review of facility policy, food storage (dry, refrigerated, frozen), dated 2016, showed:
-All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded.
-Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration.
-Leftover contents of cans and prepared foods will be stored in covered, labeled, and dated containers in refrigerators and/or freezers.
Review of facility policy, handling leftover food, dated 2016, showed:
-Leftover foods stored in the refrigerator shall be wrapped, dated, labeled with a use by date that is no more than 72 hours after the time of first use.
-Refrigerated leftovers stored beyond 72 hours shall be discarded.
-Leftover foods stored in the freezer shall be wrapped air-tight and moisture proof, dated, and labeled. The date, item, and amount shall be clearly posted.
Observation on 3/12/24 at 8:20 A.M. showed:
-Refrigerator had outdated food items including:
-Swedish meatballs, dated 3/9/24;
-Fried potatoes and sausage, dated 3/7/24;
-French toast, dated 3/9/24;
-Unsealed bag of sliced ham, dated 3/10/24;
-Dry Storage:
-Undated and opened container of 180 oz light chili powder;
-Undated and opened container of taco seasoning;
-Two Undated and opened containers of 18 oz ground white pepper;
-Undated and opened onion powder;
-Undated and opened 12 oz lemon and pepper seasoning;
-Unreadable dated 18 oz paprika;
-Undated and opened 18 oz ground allspice;
-Undated and opened 18 oz chili powder;
-Undated and opened 14 oz ground cumin;
-Undated and unlabeled shaker of cinnamon sugar.
-On Top of Stove:
-Undated and unlabeled shaker of unknown spice.
During an interview on 3/12/24 at 8:36 A.M., [NAME] A said:
-Food should be dated when opened;
-Items are thrown out after three days;
-Food is dated when it came off of the truck.
Observation on 3/14/24 at 10:56 A.M. showed two pitchers sitting in melted water bath with ice almost gone with one pitcher dated 3/11 unsweet tea and pitcher two labeled cherry outdated 3/10.
Observation on 3/14/24 at 11:30 A.M. showed:
-Fried potatoes/sausage, dated 3/7/24;
-Undated and opened package of sausage patties on bottom shelf;
-One pitcher pink lemonade dated 3/11/24;
-One pitcher sweet tea dated 3/11/24.
During an interview on 3/14/24 at 1:37 P.M., Dietary Aide A said:
-Spices should be dated when opened;
-He/She did not know when spices should be thrown out;
-Food should be dated and labeled right after he/she was done with it;
-Food was dated and labeled when it came off of the truck;
-Leftovers should be thrown away after the third day;
-Drinks should be thrown out after three days.
During an interview on 3/14/24 at 1:49 P.M., [NAME] A said:
-Food should be dated and labeled when it is opened or ready to be put away;
-Food is thrown out after three days;
-The cook was responsible for throwing out outdated food items;
-Facility dated food when food arrived off the truck;
-Drinks should be labeled and dated;
-Drinks should also be thrown out after three days from time it was made;
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-Anything that goes into the refrigerator should be dated;
-Food items should be thrown out after three days;
-He/She did not know spices should be dated when opened them;
-Spices in kitchen were dated when received but not when opened;
-Spices can be kept for one year from the date they were opened;
-He/She did not include year on dates when opened;
-Drinks can be made and left in refrigerator for three days then should be thrown out;
-All staff are expected to work as a team to monitor for expired food items and throw items out.
During an interview on 3/15/24 at 4:05 P.M., the Dietary Aide B said:
-Food should be dated with sticker labels;
-He/She wrote on food labels what item was, what day it was made, and what date it should be used by, and included initials;
-Drinks in kitchen should be dated;
-Any item in fridge is dated;
-Food is dated when it comes in off truck;
-Food items should be thrown out after it reached the three day mark;
-Drinks should be thrown out three days after they are made, unless it was milk or orange juice then would throw out when it reached expiration date.
During an interview on 3/15/24 at 4:11 P.M., Dietary Aide C said:
-He/She will label and date desserts when he/she had leftovers;
-Food should be thrown out two days after it was opened.
During an interview on 3/15/24 at 4:16 P.M., [NAME] B said:
-Food dating should be completed after opening the item and items should be thrown out after three days;
-The cook was responsible for getting rid of outdated food items.
7. Review of facility policy, sanitation guidelines, dated 2016, showed:
-All employees in the facility assisting with meal service shall exercise appropriate personal hygiene habits including wearing hair restraints.
Observation on 3/14/24 at 7:57 A.M. showed Dietary Aide A did not have on beard cover as he/she served residents trays in dining room.
Observation on 3/14/24 at 10:56 A.M. showed Dietary Aide A did not have beard net on.
Observation on 3/14/24 at 11:03 A.M. showed [NAME] A did not wear a beard net over beard.
During an interview on 3/14/24 at 1:37 P.M., Dietary Aide A said:
-Hairnets should be worn at all times in the kitchen;
-He/She did not know if he/she should have beard coverings on while working in the kitchen and did not know if kitchen had any;
During an interview on 3/14/24 at 1:49 P.M., [NAME] A said:
-He/She should wear hairnet while working in the kitchen;
-Beard coverings should be worn while working when facial hair is present;
-He/She did not wear a beard covering and he/she should have.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-He/She expected staff to wear hairnets while in kitchen;
-He/She expected staff to wear beard nets if had facial hair that extended out from face;
Observation on 3/15/24 at 4:01 P.M., [NAME] B did not have hairnet on and was in the kitchen.
During an interview on 3/15/24 at 4:16 P.M., [NAME] B said:
-He/She did not have a hair net on when he/she entered kitchen;
-A hairnet should be worn in the kitchen at all times;
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
He/She expected staff to wear hairnets and beard nets.
8. Review of facility policy, proper hand washing and glove use, dated 2016, showed:
-All employees will use proper hand washing procedure and glove usage in accordance with state and federal sanitation guidelines.
-The proper procedure for washing hands is as follows:
1. Turn on water as hot as comfortable.
2. Wet hands and apply soap.
3. Scrub 15 to 20 seconds or more: getting under nails, between fingers, and all exposed areas, such as back of hands and forearms.
4. Rinse hands thoroughly.
5. Dry hands with paper towel or air dryer.
6. Turn off faucet with paper towel.
-All employees will wash hands upon entering the kitchen from any other location, after all breaks (including bathroom and smoking breaks), and between all tasks. Hand washing should occur at a minimum of every hour.
-Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before or after working with an individual resident.
-Gloves are to be used whenever direct food contact is required with the following exception: Bare hand contact is allowed with foods that are not in ready to eat form that will be cooked or baked.
-Hard are washed before donning gloves and after removing gloves.
-Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment.
Observation on 3/14/24 at 11:05 A.M. showed floor in kitchen has pieces of food and dirt around edges of flooring. Area under the oven had not been cleaned and the oven wheels were sitting on a sticky black substance.
Observation on 3/14/24 at 11:09 A.M. showed [NAME] A washed his/her hands for ten seconds, turned the water faucet off with clean hands, then dried his/her hands with a paper towel.
Observation on 3/14/24 at 11:10 A.M. showed Dietary Aide A washed his/her hands for less than ten seconds, turned off the water faucet with clean hands.
Observation on 3/14/24 at 11:11 A.M. showed Dietary Manager washed his/her hands, turned off faucet with clean hands, grabbed paper towels, then threw paper towels away.
Observation on 3/14/24 at 11:12 A.M. showed [NAME] A washed his/her hands for eight seconds, dried off hands, used towel to turn off faucet. Threw items in trash, grabbed wash cloth out of sanitizer bucket to right of stove, wiped off the preparation table to left of stove or oven. He/She then washed his/her hands for four seconds, turned faucet off with paper towel, used same paper towel that turned faucet off with to dry his/her hands.
Observation on 3/14/24 at 11:37 A.M. showed Dietary Aide A returned from going to storeroom to grab a box of gloves. He/She did not wash hands and began putting away clean dishes.
Observation on 3/14/24 at 11:43 A.M. showed Dietary Aide A washed his/her hands for five seconds, then turned faucet off with his/her clean hands, dried hands with paper towel.
During an interview on 3/14/24 at 1:37 P.M., Dietary Aide A said:
-Hand washing steps include turning on faucet, running hands under water for twenty seconds, applying soap, scrubbing between fingernails, back of hands, rinsing, grabbing paper towel, turning off faucet, drying hands;
-He/She should not touch anything with hands after washing;
-It was unsanitary to touch faucet handle after washing his/her hands;
-He/She wash hands after touching his/her face.
During an interview on 3/14/24 at 1:49 P.M., [NAME] A said:
-When hand washing he/she should wash hands up to his/her elbows and recite the ABC's as he/she washed to wash long enough for approximately thirty seconds;
-It was not sanitary to use his/her just cleaned hands to turn faucet handle off;
-He/She did do use his/her clean hands to turn off the faucet.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-He/She expected staff to wash hands any time they changed from food. Staff needed to wash hands or should have gloves on and change gloves any time they enter kitchen or use hand sanitizer. After three uses of hand sanitizer staff should use sink and wash their hands.
During an interview on 3/15/24 at 4:05 P.M., the Dietary Aide B said:
-Hand washing should be done anytime he/she entered kitchen or after touching something
-When hand washing he/she turned on water, applied soap, rubbed hands together and scrubbed top of hands, between fingers, finger nails, and then would rinse off soap, grab paper towel, dry hands off with towel, and throw towel in trash can.
Observation on 3/14/24 at 12:20 P.M. showed Dietary Manager returned to kitchen, washed hands, turned off water with clean hands, then grabbed paper towels.
During an interview on 3/15/24 at 4:11 P.M., Dietary Aide C said:
-His/Her dishwashing routine including handling dirty dishes first, then washing hands before putting away clean dishes. He/She wore gloves and washed hands after taking gloves off.
During an interview on 3/15/24 at 4:16 P.M., [NAME] B said:
-Hand washing should be completed after every three times of using hand sanitizer;
-Hands should be washed before he/she cooks, after he/she cooked, and after touching stuff;
During an interview on 3/15/24 at 7:35 P.M., Administrator said:
-He/She expected staff to wash hands upon entering kitchen and between clean and dirty tasks;
-He/She expected staff not to touch faucet handle with clean hands;
-Hand washing should last for at least 26 seconds.
During an interview on 3/15/24 at 7:35 P.M., Regional Director of Nursing said:
-He/She expected hands to be washed upon arrival to kitchen in hand sink, whenever hands were visibly dirty, in between clean and dirty tasks, before dish washing, after dish washing with gloves, anytime application and after removal of gloves, and after any use of cleaning with solvents.
-He/She expected staff not to touch faucet handle after washing their hands.
9. Review of facility policy, food storage (dry, refrigerated, frozen), dated 2016, showed:
-Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 degrees Fahrenheit or lower. Place hanging thermometer in the warmest part of refrigerator;
-Conduct random temperature checks of food items;
-Check freezer temperature regularly;
-Keep freezer at a temperature that ensures products will remain frozen;
-Check freezer temperatures regularly.
Observation on 3/12/24 at 8:45 A.M. showed Dietary Manager placing a temperature log on the chest freezer.
During an interview on 3/12/24 at 8:45 A.M., Dietary Manager said he/she did not have a temperature gauge in the chest freezer and it was just brought to his/her attention.
Observation on 3/14/24 at 11:46 A.M. showed chest freezer now had log recordings on 3/1/24-3/5/24 for A.M. and P.M., and top of sheet had written on it start log on 3/12/24.
10. Review of facility policy, monitoring food temperatures for meal service, dated 2016, showed:
-Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures.
-Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below.
-The temperature for each food item will be recorded on the food temperature log. Foods that required a corrective action; will have the new temperature recorded with a circle around it next to the original temperature.
Review of facility policy, sanitation guidelines, dated 2016, showed:
-All hot food prepared for the steam table will have the internal cooking temperature tested before removing from the oven to ensure that the product was reached the minimum internal cooking temperature.
-All foods, both hot and cold, that are potentially hazardous food (PFH) or time/temperature control for safety food, will have the food temperature taken before the start of meal service and every one-half hour thereafter to ensure the maintenance of food temperatures on serving equipment during the entire length of meal service. All hot foods are kept on a steam table and cold foods are kept in a refrigerated unit or on ice while being held for service.
Observation on 3/14/24 at 10:56 A.M. showed noodles placed on steam table.
During an interview on 3/14/24 at 11:35 A.M., [NAME] A said:
-He/She temperature checked food after it came off the stove and before he/she put it on the steam table;
-He/She did temperature check food as it was cooking but did not write it down on log yet.
Observation on 3/14/24 at 12:33 P.M. showed the food has not been temperature checked since observation began at 10:56 A.M.
Observation of test tray on 3/14/24 at 12:36 P.M. showed fettuccine with sauce over top tested at 113.1 degrees.
During an interview on 3/14/24 at 1:37 P.M., Dietary Aide A said:
-Food should be temperature checked before it is placed on the steam table and before he/she started serving food;
-He/She documented food temperatures in log.
During an interview on 3/14/24 at 1:49 P.M., [NAME] A said:
-Food temperatures should be taken after food was heated on the stove and after food was placed on steam table;
-He/She did not temperature check the food before serving from steam table on 3/14/24.
During an interview on 3/15/24 at 3:37 P.M., Dietary Manager said:
-He/She expected the cook to temperature check food when it was being cooked, when it was held on steam table, and before it was served.
During an interview on 3/15/24 at 4:16 P.M., [NAME] B said:
-Food temperatures should be checked before he/she took food out of the stove;
-Food temperatures should be documented in the temperature logbook located in dietary office;
-He/She temperature checked food on serving line after he/she served all food to residents.
During an interview on 3/15/24 at 7:35 P.M., Administrator said food should be temperature checked before it was served.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0660
(Tag F0660)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly document a discharge to home for one of three discharged r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly document a discharge to home for one of three discharged residents, (Resident #40). The facility census was 40.
The facility did not provide a policy for discharge planning.
1. Review of Resident #40's quarterly Minimum Data Set (MDS), dated [DATE] showed:
- Long and short term memory problems;
- Physical behavior directed at others occurred one to three days;
- Verbal behavior directed at others occurred one to three days;
- Substantial to maximal assistance with eating and transfers;
- Dependent on the assistance of staff for oral hygiene, toilet use, showers, dressing and personal hygiene;
- Always incontinent of bowel and bladder;
- Diagnoses included dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), anxiety and depression.
Review of the resident's physician order sheets (POS) dated February, 2024 showed no order to discharge the resident from the facility.
Review of the resident's progress notes dated 2/4/24 at 9:00 A.M., showed staff did not document the resident's discharge from the facility.
Review of the resident's undated care plan showed it did not address the resident's discharge planning.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said when a resident is discharged from the facility, there should a physician's order to discharge the resident and staff should have documented the discharge in the progress notes.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0661
(Tag F0661)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and closed record review, the facility staff failed to complete a comprehensive discharge summary for one of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and closed record review, the facility staff failed to complete a comprehensive discharge summary for one of three discharged residents, Resident #40. The facility census was 40.
The facility did not provide a policy for discharge summaries.
1. Review of Resident #40's quarterly Minimum Data Set (MDS), dated [DATE] showed:
- Long and short term memory problems;
- Physical behavior directed at others occurred one to three days;
- Verbal behavior directed at others occurred one to three days;
- Substantial to maximal assistance with eating and transfers;
- Dependent on the assistance of staff for oral hygiene, toilet use, showers, dressing and personal hygiene;
- Always incontinent of bowel and bladder;
- Diagnoses included dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), anxiety and depression.
Record review of the resident's closed medical records showed:
- Staff did not document when the resident was discharged from the facility;
- The staff failed to have the resident or the responsible party sign and date their interdisciplinary discharge summary'
- The staff failed to complete a recapitulation of the resident's stay at the facility.
During an interview on 3/15/24 at 7:35 P.M., the Administrator said:
- There should be a recapitulation of the resident's stay;
- Staff should have documented the resident's discharge from the facility.
Nov 2023
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0742
(Tag F0742)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide protective oversight for one resident (Resident #1), who di...
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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 protective oversight for one resident (Resident #1), who displayed behaviors of self-harm including a recent attempt to commit suicide on [DATE], and failed to verbally communicate with the resident's physician regarding the residents behaviors of attempted self harm and of the resident's death, at the time the death occurred. The facility additionally failed to provide appropriate interventions and monitoring when they relied on the resident's roommate to alert staff when he/she determined the the resident needed assistance. The facility census was 45.
A review of the facility's Accidents and Incident Policy with a revision date of [DATE], showed:
- All accidents or incidents involving residents occurring on the facility premises shall be investigated and reported to the administrator;
-The nurse supervisor/charge nurse and/or the department or supervisor shall promptly initiate and document investigation of the accident or incident;
-The following data shall be include on the report:
o The date and time of the incident;
o The nature of the injury;
o The circumstances surrounding the incident;
o The time the injured person's attending physician was notified as well as the time the physician responded and his/her instructions;
o The dated and time the injured person's family was notified;
o Other pertinent information;
o The signature and title of the person completing the report;
o The Director of Nursing (DON) shall ensure the administrator receives a copy of the Report of Accident form for each occurrence.
Review of the facility's policy, Behavior Health Services, revised, February 2019, showed:
-The facility will provide residents with behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being;
-Residents who exhibit signs of emotional/psychosocial distress will receive services and support and address their individual needs;
-Staff must promote safety, privacy, socialization and dignity as appropriate for each resident and trained in ways to support residents in distress;
-Staff training includes recognizing changes in behavior that indicate psychological distress;
-Staff will implement care plan interventions that are relevant to the resident and appropriate to his/her needs;
-Staff will monitor care plan interventions and report changes in condition;
-Staff will follow protocols, and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties and history of trauma.
Review of the facility's policy, Behavioral Assessment, Intervention and Monitoring, revised, [DATE], showed:
-The facility will provide residents with behavioral health services as needed;
-Behavioral symptoms will be identified using facility-approved behavioral screening tools;
-Residents will have minimal complications associated with the management of altered or impaired behavior;
-Behavior can be a way for an individual in distress to communicate needs or express thoughts that cannot be articulated;
-The nursing staff will identify, document and inform the physician about specific details regarding changes in an individual's mental status or behavior;
-The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms including at a minim, physical changes such as constipation or pain or emotional changes such as depression and anxiety;
-Interventions will be individualized;
-Interventions will be based on assessment details that will include the frequency of behavioral symptoms, outcomes and locations of behaviors.
1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated [DATE]., showed:
-The resident had severe cognitive impairment;
-The resident used no speech;
-The resident is rarely understood;
-The resident has physical directed behaviors directed toward others;
-The resident is totally dependent on staff for activities of daily living (ADL's), bed mobility and maximum assistance for transfers and ambulation;
-Diagnoses include, quadriplegia (paralysis of all four limbs of the body), traumatic brain injury (injury to the brain caused by a forceful bump, blow, or jolt to the head or body) can be caused by a forceful bump, blow, or jolt to the head or body, that pierces the skull and enters the brain), and low blood pressure.
Review of the resident's care plan revised on [DATE] showed:
-The care plan did not address behaviors associated with traumatic brain injury.
-The care plan did not address displays of self harm;
-The care plan did not address mental health needs.
-The care plan did not address how staff are to care for a resident with known behavior of self harm by placing items around his/her neck.
-The resident had a Do Not Resuscitate Order (no heroic life saving measures or chest compressions).
Review of physician progress notes dated [DATE] showed:
-The resident can move his/her right side well;
-The resident can follow simple commands.
Review of nurse's notes dated [DATE] at 8:00 P.M., showed:
-The resident's roommate had his/her call light on and yelling for the nurse;
-The resident was half on the fall mat and half off the bed;
-The resident was not breathing, had no pulse and the resident's skin was gray in color;
-The resident's chin was tucked in toward his/her chest and liquid was bubbling up in the resident's mouth;
-The resident suddenly took a breath and stopped breathing again;
-The nurse and a nursing aide moved the resident back in bed when he/she started agonal (condition that occurs when someone who is not getting enough oxygen and is gasping for air) breathing;
-The physician was called and a message was left on his/her voicemail to call the facility as soon as possible;
-The resident was breathing and awake at this time;
-The resident's responsible party was called and he/she said not to send to the ER and just to monitor the resident;
-At 8:30 P.M., the nurse called the physician again and the physician said he/she would recommend sending the resident to the ER but if the responsible party did not want to do that he/she would abide by the responsible party's request.
Review of physician progress notes dated [DATE] showed:
-The resident has no new changes in his/her condition;
-Physical assessment and vital signs good;
-The resident was able to close his/her eyes on demand;
-The resident can understand most of what is being said to him/her.
A review of nurse's notes dated [DATE] at 6:00 A.M., showed:
-The resident was found on fall mat face down between the wall and the bed;
-The physician was notified of the fall by fax;
-No apparent injuries.
A review of nurse's notes dated [DATE], showed:
-The resident was yelling and restless;
-The resident pulled the Cardiopulmonary Resuscitation (CPR - is an emergency lifesaving procedure performed when the heart stops beating) tag (tag used to deflate the bed in quickly, in case CPR needs to be administered), out of the bed and was trying to reach the cords of the bed and the call light cord.
- Documentation did not show an assessment to determine the needs of the resident or to determine the cause of the resident's behavior.
A review of nurse's note dated [DATE] showed the resident pulled the CPR tag from the bed two times during the shift. The note did not show staff assessed or interviewed the resident to determine the cause of the behavior.
A review of nurse's noted dated, [DATE], showed:
-The resident turned himself/herself sideways in bed and grabbled the strap on the bed cushion and was attempting to wrap the strap around his/her neck;
-Physician faxed regarding the residents behavior.
-The note did not include documentation of any assessment or investigation of the incident.
Review of the residents care plan showed no new interventions or monitoring.
A review of a fax sent to Physician a, dated [DATE], with a stamped time of 10:30 A.M., showed:
-The resident becomes combative and aggressive at times;
-The resident appears depressed;
-Requesting to start him/her on an antidepressant;
-The fax was signed by LPN A.
Review of the residents care plan showed no new interventions or monitoring.
Review of nurse's notes dated [DATE] at 6:35 P.M. showed:
-The resident was found unresponsive in his/her room by the facility staff and determined that the resident was without heart sounds, respirations or pulse.
-RN B was called to the resident's room by Dietary Aide A where the resident was found on the floor;
-The resident's torso was off the bed and his/her head was on the floor;
-The resident's hands and face were purple;
-The resident had no heartbeat, and no respirations;
-Family member A was notified of the resident's death by phone;
-The DON was notified by phone;
-Facility did not start CPR, because the resident was a DNR.
-No documentation that the resident's physician had been notified of his/her death was found in the resident's record.
During an interview on [DATE] at 9:16 A.M., Dietary Aide A said:
- He/she went to pass the hall trays and the Resident #1 was on the floor and not moving so he/she told the nurse;
-He/she was unaware of any interventions related to the residents care.
During an interview on [DATE] at 9:44 A.M., Registered Nurse (RN) B said:
-He/she had checked on Resident #1 on [DATE] at around 5:30 P.M., and he/she was fine;
-On [DATE] at around 5:50 P.M., he/she was in the dining room assisting the residents when Dietary Aide A asked him/her to check on Resident #1 because he was on the floor and not moving;
-He/she knew he was deceased as soon as he/she looked at him;
-RN B told dietary aide A to get Certified Medication Technician (CMT) A to assist him/her;
-The resident was half way on the floor, the bed was in the low position and the resident's head was on the floor mat and his torso still on the bed;
-The resident was face up with the top of his head on the fall mat and his/her chin tucked in towards his/her chest;
-He/she assessed the resident for signs of life and found no pulse, no respirations and no heart sounds;
-The resident's face and hands were purple and he/she had no pulse or respirations;
-He/she was afraid this was eventually going to happened because the resident had wrapped cords around his/her neck before and thrown himself/herself on the floor in this position before;
-He/she
-There was no changes in the resident's care after the displays of self harm;
-The staff depended on the resident's roommate to notify them if the resident was ok;
-Should have dedicate staff to monitor residents that display self harm;
-He/she would monitor the resident by looking in his/her room when he/she had time;
-The aides were instructed to check when they went by his/her room and every two hours;
-He/she was unaware of any interventions that addressed the resident's displays of self harm.
-The resident could use his/her/her right side and that is how he/she would put himself/herself on the floor and grab the cords;
-The resident does not have a call light because he/she wraps it around his/her neck that is why he/she is in a room with Resident #2 so he/she can keep an eye on him/her;
-The staff go by the resident's room and try to check on him/her often, but his/her roommate wants the door closed sometimes;
-He/she thought the resident's actions were a cry for help and that the resident wanted to end his/her life;
-He/she had previously told the DON and the administrator but they both said Resident #1 is not capable of thinking or doing something like that because he/she suffers from a severe brain injury and is quadriplegic.
During an interview on [DATE] at 10:12 A.M., Licensed Practical Nurse (LPN) B said:
-He/she found Resident #1 on the floor, face up and chin tucked into neck with no pulse or respirations back in July of this year;
-The resident was gray and he/she thought initially that the resident had passed away but color and breathing returned;
-A fall mat was put in place and a bolster mattress, but he/she told the administration he/she though the resident was purposely try to throw himself/herself on the floor in this position to end his/her life.
-There was no changes in the resident's care after the displays of self harm;
-It is not a good standard of practice to depend on another resident to monitor a resident that has displayed behaviors of self harm;
-The resident should have been on 1:1 after the incident in July and after he/she started to wrap cords around his/her neck;
-He/she was unaware of any interventions related to the displays of self harm.
-He/she said she told the administrator and the DON but no one took it seriously.
During an interview on [DATE] at 10:43 A.M., Certified Nurse's Aide (CNA) B said:
-Resident #1 was constantly throwing himself/herself on the floor;
-The resident tried to wrap cords around his/her neck in the past;
-The staff had to move a bedside table out of his/her reach before because he/she would grab it and try to get to the floor;
-The resident did not have a call light because of the cords;
-Resident #2, his/her roommate would call for staff if Resident #1 was trying to get onto the floor or wrap something around his/her neck.
-He/she told the administrator and DON but the only interventions were a fall mat and bolstered mattress;
-No changes in the residents care were made after he/she told the administrator and the DON;
-No interventions were put in the resident's care plan to monitor that cords or straps were out of the resident's reach;
-The resident should have been monitored more closely with assigned staff;
-It was not safe to ask the resident's roommate to keep an eye on him;
-He/she unaware of any other interventions.
-Most staff new to keep the cords out of reach but there were times when he/she came back to work after days off to find the cords within reach of the resident.
2. A review of Resident #2's quarterly MDS, dated [DATE], showed:
-The resident has no cognitive impairment;
-The resident is dependent on staff for ADL care;
-Diagnoses included, Cerebral Palsy (a disorder that effects a person's ability to move and maintain balance), stroke and high blood pressure.
Review of Resident #2's care plan dated [DATE], showed:
-The resident requires staff assistance for bed mobility and transfers;
-The resident is dependent on staff for ADL's.
During an interview on [DATE] at 2:13 P.M., Resident #2 said:
-Resident #1 could not use the call light and that is why the facility staff roomed him/her with Resident #1;
-He/she observed Resident #1 grab the cord of the call light, the bed, or the strap on his/her bed cushion multiple times and tried to put the cord around his/her neck;
-The staff would try to keep the cords out of reach but Resident #1 would still get a hold of a cord sometimes;
-Resident #1 could use his/her right arm and pull himself/herself on the floor;
-Resident #1 has wrapped a cord around his/her neck several times and he/she has notified staff;
-Sometimes Resident #1 would wrap the bed sheet around his/her neck and then Resident #2 would ring for the nurse;
-Resident #1 started yelling out more often in the last weeks.
-It made him anxious for staff to place him/her in the room with Resident #1 because he/she felt responsible to supervise and get help for Resident #1 when needed.
During an interview on [DATE] at 2:38 P.M., Resident #2 said:
-He/she eats in his/her room most of the time;
-Resident #1 had a feeding tube so he/she was in the room during meals;
-The night Resident #1 died, he/she noticed Resident #1 had been more quiet than usual but did not think anything about it;
-When Dietary Aide A brought his/her supper tray in he/she asked him/her if Resident #1 was ok and that is when he/she noticed Resident #1 was not moving;
-RN B came into the room and told Dietary Aide A to go get CMT A;
-CMT A and RN B closed the curtain between Resident #1 and Resident #2 and that was all he/she knew.
During an interview on [DATE] at 3:01 P.M., DON said:
-He/she was made aware of Resident #1's death by the charge nurse on duty;
-No investigation was done because it was a natural death, the resident had a lot of health conditions and was a DNR (Do Not Resuscitate) code status;
-The facility put interventions in place to prevent falls;
-A fall mat was put in place, a bolstered mattress was in place and cords were out of the residents reach;
-The resident was in a room with Resident #2 because Resident #1 would ring his/her call light to let the staff know if either one of them needed help;
-He/she said the facility should not have relied on the resident's roommate to monitor the resident's safety;
-He/she had been told about the resident attempting to grab cords but he/she did not consider this behavior self harm;
-Resident #1 did not have the mental capacity to a decide to take his/her life;
-The staff checked on Resident #1 every time they walked by his/her room;
-These checks are not documented because the staff checks on everyone at least every two hours;
-Resident #1's physician was notified by the charge nurse of his/her death;
-A resident's physician should be notified of any significant change in their condition or a resident's death as soon as possible.
During an interview on [DATE] at 3:38 P.M., The Administrator said:
-He/she was made aware of Resident #1's death by the DON;
-The resident suffered from a TBI and was a quadriplegic and he/she believed that contributed to his/her death;
-Fall interventions were put in place because the resident kept putting him/herself the floor;
-He/she did not know if keeping cords out of the resident's reach was addressed on the resident's care plan;
-He/she was aware that the Resident #1 had a history of wrapping cords around his/her neck but the staff were aware and kept the cords out of reach;
-He/she would expect staff to check on Resident #1 at least every two hours or more;
-He/she did not do an investigation into Resident #1's death because the resident suffered from a TBI, and the resident was a DNR code status;
-He/she said the facility should not have relied on the resident's roommate to monitor the resident's safety;
-He/she had been told about the resident grabbing cords;
-Resident #1 was not capable of mentally making that decision to take his/her life because of the his/her TBI;
-He/she said the facility was following its policy and procedure related to the resident's care and death at the facility;
-All fall interventions should be care planned;
-If a resident exhibits self harming behaviors the physician should be called and safety interventions put into place;
-A resident's physician should be notified of any significant change in their condition or a resident's death.
During an interview on [DATE] at 11: 16 A.M. Certified Medication Technician (CMT) A said:
-The staff tried to look into the resident's room whenever we walked by;
-The resident did not have a call light because he/she tried to wrap it around his/her neck several times;
-The resident would try to pull himself/herself on the floor with his/her right arm;
-The resident started becoming more agitated and restless about three weeks ago;
-He/she thought he/she was giving up because he/she did not want to come out of his/her room as much;
-He/she said the facility should not have depended on the resident's roommate to monitor the resident's safety.
During an interview on [DATE] at 11:35 A.M., LPN A said:
-He/she sent Physician a fax on the morning of [DATE];
-The night shift staff told her the information in report that morning;
-He/she did not witness any of the behaviors himself/herself;
-He/she could not remember which staff told her about the behaviors.
During an interview on [DATE] at 9:33 A.M. the Social Services Director (SSD) said:
-There had been a change in the resident's mood within the last two or three weeks;
-The resident used to like to listen to music and set outside;
-During the last two or three weeks the resident did not want to go outside or listen to music;
-The resident did not want to joke around or do anything that he/she used to;
-He/she had a lost look in his/her eyes;
-He/she could not remember if he/she told the DON or administrator;
-The changes in the resident's mood should be care planned.
During an interview on [DATE] at 10:12 A.M., family member A said;
-Resident #1 was in a room with another resident because the facility said they needed someone to help keep an eye on him/her;
-He/she was told by Resident #1's roommate, Resident #2, that Resident #1 had attempted to wrap cords around his/her neck and kept throwing himself/herself on the floor;
-The facility did not inform him/her that Resident #1 was trying to wrap things around his/her neck or kept throwing himself/herself out of bed;
-Resident #2 said he/she was monitoring Resident #1 and he/she would ring or yell for yelp if Resident #1 was on the floor or was trying to wrap something around his/her neck;
-He/she considered the accident that resulted in the resident's TBI was a traumatic event;
-The resident would have benefited from mental health services;
-The facility did not contact her about setting up mental health service for the resident;
-The resident has not seen a mental health professional;
-The facility did not watch Resident #1 close enough;
-He/she was told about Resident #1's death by another family member and not the facility;
-He/she is supposed to be the first person to be called.
During an interview on [DATE] at 12:08 P.M. Physician A said:
-He/she considered the accident that resulted in the resident's TBI was a traumatic event;
-He/she did not recall if the facility notified him/her that Resident #1 had wrapped cords around his/her neck;
-He/she did not recall if the facility notified him/her that Resident #1 was found on the floor with his/her chin tucked into his/her neck back on [DATE], with no pulse, no respirations and purple in color;
-The facility might have notified him/her of he/she could not remember off hand;
-He/would expect the staff to monitor a resident that was displaying behaviors of self harm;
-The facility did not notified him/her that Resident #1 had died on [DATE];
-He/she had just talked to someone at the facility yesterday about this and the facility said they notified him/her by phone but he/she looked back in his phone records and messages and did not find one from the facility notifying him of Resident #1's death.
-He/she would expect the facility to keep trying to get a hold of him/her when there is a significant change in a resident's status or a death;
-He/she did not find out about Resident #1's death until he/she rounded at the facility on Saturday [DATE];
-He/she would expect to be notified with any significant changes to Resident #1's condition;
-He/she would expect to be notified when a resident expires;
-He/she was not anticipating Resident #1's death.
MO226835
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly investigate falls and put interventions in place for Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly investigate falls and put interventions in place for Resident #3 who had multiple falls. The facility census was 45.
A review of the facility's Accidents and Incident Policy with a revision date of July 2017, showed:
- All accidents or incidents involving residents occurring on the facility premises shall be investigated and reported to the administrator;
-The nurse supervisor/charge nurse and/or the department or supervisor shall promptly initiate and document investigation of the accident or incident;
-The following data shall be include on the report:
o The date and time of the incident;
o The nature of the injury;
o The circumstances surrounding the incident;
o The time the injured person's attending physician was notified as well as the time the physician responded and his/her instructions;
o The dated and time the injured person's family was notified;
o Other pertinent information;
o The signature and title of the person completing the report;
o The Director of Nursing (DON) shall ensure the administrator receives a copy of the Report of Accident form for each occurrence.
1. Review of Resident #3's Quarterly MDS dated [DATE] showed:
-The resident had severe cognitive deficits.
-1-3 days of yelling, screaming or cursing at others over a 7 day period.
-Wandered daily.
-Independent to set up assistance with ADL's.
-Diagnoses of Dementia and unspecified injury of the head.
Review of the resident Comprehensive Care Plan dated 10/5/22 showed:
-He/She has a potential for falls.
-A goal of no falls in 90 days.
- Staff are directed to provide increased monitoring with ambulation or pacing.
- Staff are to give frequent reminders to the resident to remove his/her hands from pockets when ambulating.
-Remind the resident not to run.
-Remind him/her to keep his/her area free of clutter.
-Encourage him/her to use handrails.
Review of the resident's medical record showed falls occurred on:
- 10/6/23 at 4:10 A.M. the resident was found on the floor in the hall after a Nurse Aide heard a fall. He/She had a small amount of blood on his/her nose.
-10/15/23 at 6:20 A.M. the resident was found on the floor in front of his/her recliner. He/She said they slid out of the chair. The doctor and the family were notified.
-10/18/23 at 11:00 P.M. the resident was found on the floor in the hallway with a skin tear to his/her elbow and an abrasion to his/her head.
-No updates were noted on the care plan.
-No notes of interventions put into place to prevent falls.
-No notes that a fall was reviewed by the Interdisciplinary Team (IDT).
During an interview on 11/1/23 at 10:58 A.M., Nurse Aide A said:
-He/She has worked in the facility about a month.
-He/She did not know where the care plans were.
-He/She just knows what to do for specific residents who fall.
-He/She was told of any falls during report.
-He/She would notify the nurse of a fall. The nurse completes all paperwork.
-He/She was not aware if staff have meetings to discuss resident falls.
During an interview on 11/1/23 at 2:20 P.M. Registered Nurse A said:
-He/She has no idea where care plans are.
-He/She did not update care plans, the Director of Nursing (DON) does.
-He/She did not know what interventions to put into place for a resident who falls.
-He/She had no education on a Root Cause Analysis (RCA-the process of discovering the root causes of problems in order to identify appropriate solutions.), what it is or how to complete it.
-There was a fall packet that was completed with falls and turned in to the DON.
During an interview on 11/1/23 at 5:10 P.M. the DON said:
-The charge nurse should be notified of any fall, and begin an assessment of the involved resident.
-A fall packet that contains an incident report and fall risk assessment is completed with every fall.
-Care plan interventions may be done by the Charge Nurse. He/She was unsure if the nurses knew to complete that task.
-She did not believe there was enough staff to prevent falls in the facility.
-The IDT meets weekly for a verbal risk meeting and discuss falls, what worked, what didn't and what really happened. The meeting and findings have not been documented.
-Standard is if not documented it is not done.
During an interview on 11/1/23 at 6:00 P.M. the Administrator said:
-The facility was struggling for staff.
-Falls were reviewed by the IDT in weekly risk meeting.
-The weekly risk meeting needs to be documented.
MO226835
MO226224
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, facility staff failed to provide appropriate incontinence care for two resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide appropriate incontinence care for two residents who required assistance.(Resident #4 and #5) of seven sampled residents. The facility census was 46.
The facility provided policy, Dementia Care, dated November 2018 showed in part:
-Direct care staff will support the resident in initiating and completing activities and tasks of daily living.
1. Review of Resident #4's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 7/24/23 showed:
-Brief Interview of Mental Status (BIMS) of 99; indicated significant cognitive loss.
-No behaviors
-Partial to moderate assistance by staff for Activities of Daily Living (ADL's: general activities necessary for one to function and live independently, such as bathing, dressing, toileting, transferring (getting in and out of bed or chair), eating, and continence.)
-Always incontinent of bladder. (the inability to control the passage of urine)
-Diagnoses of Dementia ( the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Anxiety (a feeling of fear, dread, and uneasiness, that may cause a person to sweat, feel restless, tense, and have a rapid heartbeat.), constipation and history of left radius (wrist bone) fracture.
Review of the resident's undated Comprehensive Care Plan showed:
-He/she requires assistance to complete ADL's safely.
-Allow him/her to make choices.
-Supervision for toileting.
Continuous observation on 11/1/23 showed:
-10:20 A.M. the resident was walking in the main hall of the secured care unit.
-10:43 A.M. the resident had his/her sweat pants down to his/her thighs and was attempting to sit in a dining room chair. Nurse Aide (NA) A walked by the resident, took a breakfast tray into the resident's room and then returned to the hallway. NA A noticed the resident and assisted him/her to pull sweat pants into correct position and walked away.
-10:47 A.M. the resident pulled his/her pants down around his/her thighs and walked around the dining room.
-10:49 A.M. Transportation Aide assisted the resident to adjust and pull up sweat pants then walked away.
-10:50 A.M. the resident began walking the hallway.
-11:03 A.M. the resident was standing in the hall near the dining room.
-11:45 A.M. the resident was walking the hallway. His/her pants were sagging in the front and back genital areas.
-11:57 A.M. the resident was told to sit at the dining room table by the Physical Therapy Assistant.
-12:12 P.M. the resident was given his/her meal tray.
-12:35 P.M. the resident got up from the table, picked up meal trash, and began walking around the dining room.
-12:49 P.M. the resident walked into the hall.
-1:11 P.M. the resident continued to walk in the hall.
1:22 P.M. NA A assisted the resident to his/her room and into the bathroom. The resident's pants and incontinent brief were removed. Brief saturated with moderate amount of urine. Incontinent care provided by NA A.
2. Review of Resident #5's Quarterly MDS dated [DATE] showed:
-BIMS of 99; indicated severe cognitive deficit.
-No behaviors
-Supervision and touch assist for ADL's.
-Frequently incontinent of bladder.
-Diagnosis of Dementia, depressive disorder, and chronic kidney disease (a gradual loss of kidney function), Diabetes Mellitus (disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces)
Review of the resident's Comprehensive Care Plan dated 6/15/23 showed:
-He/she is incontinent of bowel and bladder and wears briefs.
-Give me frequent reminders to use the toilet.
-Take him/her to the bathroom.
-Remind resident to alert staff if he/she has been incontinent.
Continuous observations on 11/1/23 showed:
-10:43 A.M. the resident was sitting at the dining room table.
-12:15 P.M. the resident was given his/her meal tray.
-12:51 P.M. Registered Nurse (RN) A assisted the resident up from the dining room table to his/her room. The nurse attempted to administer the resident's insulin. The resident refused. RN A left the room. The resident walked to the dining room. His/her pants were sagging in the front and back genital areas, and had an orange sized area of wetness on the left lower buttock.
-12:58 P.M. The Administrator assisted the resident from the dining room, into his/her room and bathroom. NA A entered bathroom, removed the saturated brief and assisted with incontinent care. The resident's inner buttocks were dark pink/red in color.
During an interview on 11/1/23 at 1:07 P.M. NA A said:
-He/she is the only aide on the hall today.
-There have been other staff checking in with him/her to assist as needed.
-It was difficult to meet the resident's needs today.
-He/she is doing the best he/she can.
-He/she tries to check resident's every 2 hours for incontinency.
During an interview on 11/1/23 at 5:10 P.M. the Director of Nursing (DON) said:
-He/she would expect every resident to be toileted or freshened up every 2 hours and as needed.
-He/she would expect Licensed Nurses to offer and assist to toilet residents.
During an interview on 11/1/23 at 6:00 P.M the Administrator said:
-The facility struggles with staffing.
-He/she expects residents to be offered or toileted every 2 hours or as needed.
MO226224
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 F0741
(Tag F0741)
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 train staff to adequately care for one resident (Resident #7) with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to train staff to adequately care for one resident (Resident #7) with behavioral health care needs. The facility census was 46.
Review of the facility's policy Staffing, Sufficient and Competent Nursing, dated August 2022 showed in part:
-Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work rules or occupational functions successfully. Staff must meet the skills and techniques necessary to care for resident needs including
(but not limited to) Behavioral health, Psychosocial care, Dementia care, Person centered care, and Communication.
Review of the facility policy Dementia-Clinical Protocol dated November 2018 showed in part:
-Nursing assistants will receive training in the care of residents with dementia and related behaviors. Performance reviews will be conducted annually and in-service education will be based on the results of the reviews.
1. Review of Resident #7's quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 8/17/23, showed:
-Brief Interview of Mental Status (BIMS) of 99 or not assessed; indicated significant cognitive loss
-No behaviors
-Independent to supervision with Activities of Daily Living (ADL's: activities done to provide care for oneself such as bathing, eating, dressing, moving into and out of bed, using the toilet, and etc.)
-Diagnoses of Alzheimer's Disease ( a disease of the brain that effects memory and thinking), Bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows ) and Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain)
Review of Resident #7's undated Comprehensive Care Plan showed:
-He/she displays physically aggressive behaviors. He/she resides on the secure memory unit.
-He/she will not display any physically aggressive behaviors.
-Identify causes for behavior and reduce factors that may provoke the resident.
-Monitor and document the behavior.
-Praise the resident for demonstrating desired behavior.
2. Review of Resident #6's Quarterly MDS dated [DATE] showed:
-BIMS of 6, indicated cognitive loss.
-Behaviors that are not directed at others such as pacing, wandering, and rummaging occurred 1-3 days a week.
-Independent to supervision with ADL's.
-Diagnoses of Major Depression, Delusional disorder (when a person has one or more non-bizarre (situations that are not real but also not impossible) thoughts that cannot be explained by any other condition.)
Observation on 11/1/23 at 12:59 P.M. showed Resident #7 was at the entrance door to the secured unit, pushing against the door with his/her backside. He/she verbalized he/she did not want to return to the unit. An unknown staff member, on the opposite side of the door,was counter pushing the door. Nurse Aide (NA) A calmly attempted to encourage the resident to move away from the door. The resident became increasingly upset as the unknown staff member continued to push against the door. At 1:00 P.M. the unknown person on the opposite side of the door was successful in pushing the door shut. Resident #7 began walking up and down the hallway cursing at staff and other residents. The exit door was opened by staff to reveal Registered Nurse (RN) A was the staff member pushing the door shut. At 1:07 P.M. Resident #7 was in the dining room, he/she was talking loudly, he/she reached out and grabbed Resident #6's face and chin with his/her right hand. Resident #7 released Resident #6 when the CMS surveyor called out for assistance from the Administrator. Resident #7 then walked to his/her room and laid on the bed.
During an interview on 11/1/23 at 10:58 A.M. NA A said he/she had worked in the facility about a month. He/she is unsure where the resident care plans are. He/she is the only staff member scheduled on the secured unit, typically there are more staff. Other staff have checked in with him/her for assistance. He/she felt it was difficult to meet the resident's needs without more assistance. He/she has not had any Dementia education.
During an interview on 11/1/23 at 2:20 P.M. RN A said he/she does not have any idea where care plans are for the residents. He/she was attempting to shut the Special Care Unit door so the resident did not get out, since the resident is difficult to get back onto the unit once he/she is off. He/she didn't intend to hurt the resident. He/she had brief Dementia education on line when he/she started. He/she started about six weeks ago. He/she has not had any resident specific or further Dementia education.
During an interview on 11/1/23 at 5:10 P.M. the Director of Nursing said:
-There has been no formal education for Dementia care.
-Relias is used for staff education. Relias is all online education.
-He/she does not believe that RN A intended to harm Resident #7. RN A was attempting to prevent Resident #7 from eloping. He/she does not believe pushing the door against the resident is the appropriate way to prevent the resident from leaving.
During an interview on 11/1/23 at 6:00 P.M. the Administrator said:
-Resident #7 had exited the secured unit previously and almost dumped coffee on another resident.
-He/she believed the nurse had thought of the previous time the resident left the unit, and did not intend to be mean.
-Education is online and in person as needed.
-He/she would not expect staff to push against the door when a resident is trying to leave. He/she would expect them to attempt to redirect the resident away from the door.
MO226224
Dec 2022
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0570
(Tag F0570)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview and record review, the facility failed to maintain a surety bond that was equal or greater [NAME] one and on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview and record review, the facility failed to maintain a surety bond that was equal or greater [NAME] one and one-half times the average monthly balance for the residents' personal funds for the last 12 consecutive moths from December 2021 through November 2022. This has the potential to affect all residents who had money in the trust account. The census was 43.
Review of the facility Surety Bond Policy dated March 2021 showed:
-Our facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility.
-Policy Interpretation and Implementation
-Surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company
agree to compensate the resident for any loss of residents' funds that the facility holds, accounts for, safeguards, and manages.
-This facility holds a surety bond to guarantee the protection of residents' funds managed by
the facility on behalf of its residents.
-All funds (including refundable deposits) entrusted to the facility for a resident are covered by the surety bond.
-Inquiries concerning the financial security of personal funds managed by the facility should be referred to the administrator.
Record review on 12/7/2022 of the residents' personal funds account for the last 12 consecutive months from December 2021 to November 2022 showed:
-The facility's current approved bond amount equaled $32,000
-The average monthly balance for the residents' personal funds equaled $24,660.30 (which was determined using the total of each ending balance for the last 12 months bank statements plus the petty cash and divided by 12 months)
-An average monthly balance of $24,660.30 ($25,000, when rounded to the nearest $1,000) required a bond of at least $37,500
-A new bond continuation certificate was secured on 12/7/22 for $35,000 to become effective 12/15/22 and ending 12/15/2023.
During an interview on 12/8/22 at 3:39 P.M. with Office Manager said:
-He/she monitors bond amount and sends it up to corporate to ensure it is accurate.
-He/she is not aware of the current bond amount.
During an interview on 12/8/22 at 3:42 P.M. with Administrator said:
-The business office manager and administrator should be involved in monitoring the bond amount
-The current bond is $32,000 which was increased yesterday to $35,000 to go into effect on December 15, 2022.
-He/she and corporate secured a new bond amount yesterday after doing internal calculations.
-He/she determined they were using the wrong fund amounts to calculate required bond amount.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 staff treated residents with dignity and respe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect when staff stood while assisting two sampled residents with eating (Residents #1 and #10) and failed to provide assistance with grooming for seven residents (Residents #3, #7, #9, #20, #23, # 30 and #41). The facility census was 43 residents.
Review of facility policy, dated 2001 and revised February 2021, showed:
- Policy Statement: 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 an self-esteem;
- When assisting with care, residents are supported in exercising their rights. For example,
residents are:
a. groomed as they wish to be groomed (hair styles, nails, facial hair, etc.);
e. provided with a dignified dining experience.
1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/9/22, showed:
- Requires total dependence in bed mobility, transfer, eating, toilet use, dressing, and personal hygiene;
- Always incontinent;
- Diagnoses included seizure disorder or epilepsy and traumatic brain injury.
Review of the resident's physician's orders, dated December 2022, showed:
- Diagnoses of dysphagia (difficulty or discomfort in swallowing), seizure disorder, abnormal pelvis, hip, and spine, traumatic brain injury, chronic pain, muscle spasms, neuropathy, and constipation.
Review of the resident's undated care plan showed:
- Resident requires total assistance with Activities of Daily Living (ADLs);
- Resident fed by staff, give resident time to swallow each bite;
- Requires total assistance with meals;
- He/she should be observed while eating meals.
Observation on 12/5/22 at 12:15 P.M., showed staff stood over the top of the resident and fed him/her.
Observation on 12/6/22 at 12:33 P.M., showed staff stood over the top of the resident and fed him/her.
2. Review of Resident #10's quarterly MDS dated [DATE], showed:
- BIMS score of 99; which indicates a Staff Assessment for Mental Status to be conducted; Resident was unable to do assessment; Resident has short term and long term memory problems;
- No behaviors;
- Requires extensive assistance with transfers, dressing, toileting, bed mobility, hygiene, and eating;
- Active Diagnoses are Alzheimer's Dementia, muscle weakness, and Osteoarthritis (is the most common form of arthritis).
Observation on 12/6/22 at 12:21 P.M. showed Registered Nurse (RN) A stood next to the resident to feed him/her.
During an interview on 12/7/22 at 3:50 P.M., CNA C said staff should sit next to residents who require assistance when feeding them.
During an interview on 12/8/22 at 9:15 A.M. CNA B said:
- He/she should sit to assist residents with their meals.
3. Review of Resident #30's MDS, a federally mandated assessment completed by facility staff, dated 10/17/22, showed:
- Diagnosis of stroke;
- He/she requires physical help in part of bathing activity with setting up.
- Resident requires partial/moderate assistance with showering bathing self.
Review of the resident's Initial baseline care plan, dated 11/4/21, showed:
- Requires supervision and verbal cues and assist of one staff for dressing;
- Requires one or two person assistance with personal hygiene.
Review of the resident's care plan undated showed:
- Requires assistance to complete daily activities of care safely;
- Approach: Assist me with my hair.
Observation on 12/5/22 at 11:56 A.M., showed the resident in dining room. His/her hair appeared unbrushed or combed with large flat areas on the back of his/her head where he/she had been laying.
Observation on 12/8/22 at 11:08 A.M., showed the resident walked down the hallway with disheveled hair that had not been brushed or combed.
4. Review of Resident #9's MDS, dated [DATE], showed:
- Diagnoses included cerebral infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) , muscle weakness, spondylosis (disease of musculoskeletal system and connective tissue), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the end of bones wears down)
- Requires partial/moderate assistance with toileting hygiene, upper body dressing and substantial /maximal assistance with shower/bathe self;
- Resident requires limited assistance with dressing and personal hygiene staff provide guided maneuvering of limbs.
Observation on 12/6/22 at 8:19 A.M., showed:
- His/her hair appeared to be unbrushed;
- The resident had an area on the back of his/her head which was flattened with his/her hair flat against his/her head.
5. Review of Resident #7's MDS, dated [DATE], showed:
- Diagnoses of cerebral infarction (a condition also known as a stroke or not enough blood getting through certain blood vessels in your brain), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors)
- Requires one person physical assistance with dressing, personal hygiene, and bathing;
- Has impairment on one side and uses a cane; the resident is not steady but able to stabilize with human assistance in moving from seated to standing position, walking, moving on and off toilet;
- Resident requires substantial/maximal assistance from staff for more than half the effort with toileting hygiene, shower/bathing self.
Observation on 12/5/22 at 1:47 P.M., showed poor hygiene, the resident's fingers are covered in orange Cheeto dust. Hair was going in all different directions.
Observation on 12/6/22 at 8:20 A.M., showed the resident's hair going in all different directions at breakfast table.
6. Review of Resident #23's MDS, dated [DATE], showed:
- Diagnoses of alcohol use, alcohol-induced persisting dementia, alcohol-induced persisting amnestic disorder (a disruption in memory brought about by the enduring impacts of alcohol), and metabolic encephalopathy (a condition that causes an alteration in consciousness) ;
- Requires limited assistance with eating with staff providing guided maneuvering of limbs;
- Dependent and helper does all of the effort with eating, oral hygiene, toileting, bathing, and dressing;
- Resident is in wheelchair;
- Resident has no speech and is rarely/never understood.
Observation on 12/5/22 at 11:56 A.M., showed the resident in dining room with unbrushed hair that appears to not have been brushed since he/she was in bed.
7. A review of Resident #20's quarterly MDS, dated [DATE], showed:
-Diagnosis of Alzheimer's disease and Depression
-Resident requires limited assistance with personal hygiene and dressing with one person physical assistance
Review of the resident's undated care plan showed:
-Needs supervision assistance from staff with activities of daily living cares
-CNA to give resident verbal cues to help prompt
-CNA to place resident's supplies on bedside table within reach
-CNA to praise resident when a grooming, bathing, or hygiene task is successfully completed
Observation on 12/5/22 at 11:56 A.M. showed:
-Resident sitting at lunch with hair that was unbrushed or combed showing large flat areas on back of heads where he/she had been laying.
8. Review of resident #3's quarterly MDS assessment, dated 11/17/22, showed:
-Diagnosis of muscle weakness, age-related osteoporosis with pathological fracture, atherosclerosis of native arteries of left leg with ulceration of other part of foot
-Requires substantial/maximal assistance with shower/bathing self, partial moderate assistance with toilet hygiene
-Requires dressing by a one person physical assist
-Uses a wheelchair
Review of the resident's care plan undated showed:
-He/she requires staff assistance for all ADL's at different levels
-He/she needs set up assistance with grooming
Observation on 12/5/22 at 11:56 A.M. showed:
-Resident sitting at lunch with hair that was unbrushed or combed showing large flat areas on back of heads where he/she had been laying.
During an interview on 12/8/22 at 9:07 A.M., Certified Medication Technician (CMT) A said:
- He/she can locate resident specific care needs in resident's care plan.
9. Review of Resident #41's quarterly MDS, dated [DATE], showed:
- A Brief Interview for Mental Status (BIMS) score of 99; which indicates a Staff Assessment for Mental Status to be conducted; Resident was unable to do assessment; short term and long term memory problems;
- No behaviors;
- Requires one staff assistance with transfers, dressing, toileting, and dressing;
- Requires staff to set up for bed mobility and eating;
- Active Diagnoses are high blood pressure, Dementia without behaviors, Diabetes Mellitus II, and acute kidney failure.
Observation on 12/5/22 at 11:52 A.M., showed:
-the resident had a patch of chin hairs that were two inches by two inches that curled under their chin that was an inch in length.
Observation on 12/6/22 at 2:13 P.M. showed the resident still had hairs on his/her chin.
Observation on 12/7/22 at 8:44 A.M. showed the resident still had hairs on his/her chin.
During an interview on 12/7/22 at 9:25 A.M. CMT A said staff should offer shaving to residents on their shower days, but they often refuse.
During an interview on 12/7/22 at 9:34 A.M. LPN A said staff should shave residents on shower days at least two times a week and as needed.
During an interview on 12/8/22 at 9:38 A.M. the Interim Director of Nursing (IDON) said residents should get shaved on shower days; it is part of their bathing hygiene.
During an interview on 12/8/22 at 12:14 P.M. the Administrator said he/she expects everyone should be shaved every shower day or at least looked at daily for chin hairs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #1's MDS, dated [DATE], showed:
- Requires total dependence with bed mobility, transfer, eating, toilet us...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #1's MDS, dated [DATE], showed:
- Requires total dependence with bed mobility, transfer, eating, toilet use, dressing, and personal hygiene;
- Always incontinent;
- Diagnoses include seizure disorder or epilepsy, and traumatic brain injury.
Review of physician's orders dated December 2022 show:
-Diagnosis of dysphagia, seizure disorder, abnormal pelvis, hip, and spine, traumatic brain injury, chronic pain, muscle spasms, neuropathy, and constipation
Review of the resident's undated care plan, showed:
- The resident requires total assistance with activities of daily living.
Observation on 12/5/22 at 2:31 P.M. showed the resident laying in her bed, his/her call light hanging off the dresser and not within reach.
Observation on 12/6/22 at 2:13 P.M. showed the resident sat in his/her room in a geri-chair (a large, padded chair that is designed to help seniors with limited mobility). The residents call light draped over his/her dresser not within reach.
Observation on 12/7/22 at 8:10 A.M. showed the resident lay in his/her bed with the door closed. The call light hung on the dresser know 3 feet (') from the resident's bed and out of his/her reach.
3. Review of Resident #26's MDS, dated [DATE], showed:
- Requires total dependence for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene, and bathing;
- Resident is always incontinent of bowel and bladder;
- Diagnoses of bipolar disorder, disorder of muscle unspecified, muscle weakness, idiopathic peripheral autonomic neuropathy (a condition affecting the nerves in the feet), bilateral primary osteoarthritis of knee (a painful degenerative condition that reduces mobility and can make daily tasks difficult to manage), cognitive communication deficit, epilepsy unspecified, and unspecified intellectual disabilities.
Observation on 12/7/22 at 8:08 A.M. showed the resident lying in bed, yelling that he/she needs to get up. The resident's call light was draped over the bedside table approximately 1 1/2' away from him/him and out of reach.
4. Review of Resident #28's MDS, dated [DATE], showed:
- Diagnoses included disease of circulatory system and unspecified dementia;
- Has unclear speech
- Moderate cognitive impairment, with no BIMS score;
- Totally dependent on staff for transfers, personal hygiene, self-cares, and toilet use.
Observation on 12/5/22 at 10:51 A.M. showed the resident laying in bed and his/her call light laying on floor behind residents bed.
Observation on 12/5/22 at 2:31 P.M. showed the resident's in his/her wheelchair, the call light pinned to the top of a blanket over a foot away from resident not within his/her reach.
Observation on 12/7/22 at 8:08 A.M. showed the resident lay in bed with no call light in reach. The residents call light was on floor underneath the call light wall plug.
During an interview on 12/7/22 at 3:50 P.M. CNA C said:
-Call lights should be within reach to the residents.
- He/she usually tried to put the call lights on the residents' beds.
During an interview on 12/8/22 at 9:07 A.M. CMT A said resident call lights should be kept within the residents' reach.
During an interview on 12/8/22 at 9:15 A.M. CNA B said:
-Resident call lights should be with them. He/she makes sure call light is always on residents' bed or on their chair.
-When he/she lays residents down, he/she puts call light in bed with them where they can reach it.
During an interview on 12/8/22, at 9:38 A.M. the Interim Director of Nursing (IDON) said staff should put call lights within residents' reach.
Based on record review, observation, and interview, the facility failed to ensure four of four sampled residents (Residents #1, #2, #26, and #28) who were dependent on staff for activities of daily living, consistently had access to a call light or other means of summoning staff when needed. The facility census was 43.
Review of facility policy, Call System, Resident, dated September 2022, showed:
- Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor
- If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan
1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/22, showed:
- A Brief Interview for Mental Status (BIMS) score of 99; which indicates a Staff Assessment for Mental Status to be conducted;
- Resident has short term and long term memory problems;
- No behaviors;
- Requires one staff assistance with transfers, dressing, hygiene, and toileting;
- Requires staff to set up for bed mobility and eating;
- Active Diagnoses are high blood pressure, Anxiety, Depression, and Alzheimer's disease.
Observation on 12/5/22 at 2:16 P.M., showed as the resident laid in bed, his/her call light was attached to their roommate's two-wheeled walker.
Observation on 12/8/22 at 8:26 A.M., showed as the resident laid in bed, his/her call light was no longer attached to his/her roommate's walker, but was laying on the floor behind the walker.
During an interview on 12/8/22 at 8:54 A.M. Certified Medication Technician (CMT) B said staff should be sure they put call lights within reach of resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to hold residents' monies separate from facility money when they did n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected eleven residents. The facility's census was 43.
Review of facility policy titled 'conveyance of Resident Funds' showed:
-Any funds on deposit with the facility are refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction or death, as applicable
-The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate) jurisdiction per state law), as applicable, within thirty days from the date of the resident's discharge or eviction from the facility, or death.
Review of Interim Aged Analysis Summary, dated 12/5/22, showed:
-Resident #145 (discharged [DATE]) had a negative balance of -4,104.00
-Resident #146 (discharged [DATE]) had a negative balance of -152.00
-Resident #147 (discharged [DATE]) had a negative balance of -607.66
-Resident #148 (discharged [DATE]) had a negative balance of -50.00
-Resident #149 (discharged [DATE]) had a negative balance of -947.00
-Resident #150 (discharged [DATE]) had a negative balance of -1,179.00
-Resident #151 (discharged on 11/15/22 had a negative balance of -831.55
-Resident #43 (discharged on 9/28/22) had a negative balance of -583.50
-Resident #153 (discharged on 10/10/22) had a negative balance of -3242.00
-Resident #154 (discharged on 8/4/22) had a negative balance of -140.00
-Resident #155 (discharged on 8/9/22) had a negative balance of -569.88
During an interview on 12/8/22 at 10:30 A.M. Office Manager said:
-Resident #145 has not been issued a check, with that large of amount she would need to send to corporate to be approved.
-Resident #146 has not been issued a check.
-He/she has no reason for checks not being issued other than he/she is new at his/her job still learning how to all that. He/she has been in position since July.
-Resident #147 has not been issued a check. It has not been entered into system for corporate approval.
-Corporate is responsible for issuing checks. He/she is responsible for entering it into the system and corporate issues the checks.
-Resident #148 information has been entered for corporate on 10/1/22
-Resident #149 information has been entered for corporate on 8/26/22
-Resident #151 is at wound clinic and will be returning to facility in a couple of weeks
-Resident #43 has not been entered for corporate, he/she resided in facility only for a short term
-Resident #153 passed away in October, has not been entered for corporate
-Resident #154 passed away in August, has not been entered for corporate
-Resident #155 was paid on 10/21/22 in amount of 569.88.
During an interview on 12/8/22 at 12:09 P.M. the Office Manager said:
-He/she does not have a whole lot of training but believes resident funds are supposed to returned upon discharge within three months.
-He/she states she was not aware resident funds were to be returned within 30 days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to notify the resident and/or resident representative 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 notify the resident and/or resident representative of transfers and the reason for transfer in writing. This affected three of three sampled residents (Resident #6, #14, and #34). Facility census was 43.
Review of facility policy, Transfer or Discharge Notice, dated March 2021, showed:
-The resident and representative are notified in writing of the following information: specific reason for transfer or discharge, effective date of the transfer or discharge, and the location to which the resident is being transferred or discharged .
1. Review of Resident #6's 5 day Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/24/22, showed:
-No Brief Interview for Mental Status (BIMS) score. This indicates the resident is never/rarely understood.
-Diagnosis include: coronary artery disease (damage in the heart's major blood vessels), heart failure, urinary tract infection, Alzheimer's Disease, and depression.
Review of physician notes showed:
-On 10/14/22: 10/12/22 requested ER evaluation due to mental status changes. Orders to apply oxygen and if no improvement send to ER. Same day resident having strange behaviors. Found on floor. On 10/12/22 seen resident as requested for ER visit due to altered mental status.
Review of the residents medical record showed:
-No documentation regarding the specific reason for transfer or discharge, effective date of the transfer or discharge, and the location to which the resident is being transferred or discharged .
2. Review of Resident #14's significant change MDS, dated [DATE], showed:
-No BIMS score.
-Diagnosis include: heart failure and dementia.
-On hospice.
Review of nurses notes showed:
-On 9/14/22: Resident pale, diaphoretic, increased respirations, chest congestion, and lethargic. Doctor called. New order to send to ER. Family notified and agreed.
-No documentation of transfer letter given.
-On 9/21/22: readmitted to facility. Diagnosed with pneumonia.
3. Review of Resident #34's quarterly MDS, dated [DATE], showed:
-No BIMS score.
-Diagnosis include: traumatic brain injury (TBI), and quadriplegia (a form of paralysis that affects all four limbs).
Review of nurses notes showed:
- On 10/6/22: Resident found between bed and wall in room. Resident was head first on floor. Left side of face and orbital swelling noted. Doctor and family notified. ER evaluation ordered.
- On 10/6/22: Resident returned with no acute injury identified.
- No documentation of transfer letter given.
During an interview on 12/06/22 at 03:00 P.M. Social Services said:
-He/she does not do any transfer letters.
-Nursing would probably be responsible for that.
During an interview on 12/06/22 at 3:10 P.M. the Interim Director of Nursing said:
-Nursing does not provide a written notice for transfers.
-Information is given verbally and documented in a note.
-He/she was not aware of the written transfer letter requirement.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement resident centered care plans wh...
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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 develop and implement resident centered care plans when the facility did not have a care plan that addressed seizures or anticoagulants for Resident #18, did not implement the repositioning care plan for Resident #34 and failed to implement the oxygen, falls, and contractures care plan for Resident #1. Facility census was 43.
Review of facility policy, Care Plans, Comprehensive Person-Centered, dated March 2022 showed:
-A care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
-The interdisciplinary team (IDT), in conjunction with the resident and family, develops and implements a comprehensive, person-centered care plan for each resident.
-The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
-The care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, includes goals and desired outcomes.
-Assessments of residents are ongoing and care plans are revised as information about the residents and conditions' change.
-The IDT reviews and updates the care plan when there has been a significant change, when desired outcome is not met, when resident has been readmitted from hospital stay, and at least quarterly.
Review of facility policy, Care Planning - Interdisciplinary Team, dated March 2022, showed:
-The IDT is responsible for development of care plans.
-Care plans are based on resident assessments and developed by the IDT.
-The IDT includes but is not limited to: nursing assistant, registered nurse, and other staff as appropriate or necessary to meet the needs of the resident.
Review of the facility policy, Repositioning, dated May 2013, showed:
-Provide guidelines for evaluation of repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents.
-Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.
-Residents who are in bed should be on at least an every two hour repositioning schedule.
-Residents who are in a chair should be on an every one hour repositioning schedule.
-Check the care plan to determine specific repositioning needs.
1. Review of Resident #18's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 12/06/22, showed:
-Brief Interview for Mental Status (BIMS) score 99. This indicates severe cognitive impairment.
-Diagnosis include: renal failure, dementia, and seizures.
-Atrial Fibrillation (heart arrhythmia) not listed as an active diagnosis.
Review of December 2022 physician order sheet showed:
-Eliquis (blood thinner) 5 milligrams (mg) twice daily (BID) for Atrial Fibrillation; start date 7/1/22.
-Depakote 500mg 2 tabs at bedtime (HS) for seizures; start date 7/1/22.
Review of the care plan, dated 9/17/22, showed:
-Nothing about seizures.
-Nothing about anticoagulant usage.
2. Review of initial care plan, dated 3/7/22 showed turn assist with two staff every two hours.
Review of an undated Braden Risk Assessments (risk for pressure sores) showed a score of 12 which indicates the resident is a high risk for pressure sores.
Review of Resident #34's quarterly MDS, dated [DATE], showed:
-No BIMS score.
-Diagnosis include: traumatic brain injury (TBI) and quadriplegia (a form of paralysis that affects all four limbs).
-Total dependence on staff for bed mobility and transfers; requires two assist.
Review of care plan, updated 11/30/22, showed:
-Potential for skin breakdown; turn and reposition me according to my turn schedule.
-Needs help repositioning.
Review of December 2022 physician order sheet showed no orders for repositioning.
During a continuous observation on 12/07/22 from 12:33 P.M to 3:30 P.M. showed no staff entered residents room and repositioned.
During an interview on 12/08/22 at 11:10 A.M. CNA B said:
-Staff check residents care plans/chart for care needs required.
-Resident #34 should be turned and checked between meals and after meals.
3. Review of Resident #1's MDS, dated [DATE], showed:
-Requires total dependence in bed mobility, transfer, eating, toilet use, dressing, and personal hygiene
-Always incontinent
-Diagnoses include seizure disorder or epilepsy, traumatic brain injury
Review of resident #1's physician's orders dated December 2022 show:
-Diagnosis of dysphagia, seizure disorder, abnormal pelvis, hip, and spine, traumatic brain injury, chronic pain, muscle spasms, neuropathy, and constipation
-Oxygen PRN at 2 liters
-Right elbow splint on while up in wheel chair
-Left hand palm protector to be worn at all times except to wash hand or shower
-May use rolled washcloth as palm protector both hands
-Oxygen stat every shift, notify doctor if below 90%
-Oxygen at 2 liters via nasal cannula to keep saturations above 90% PRN for shortness of air
Review of resident #1's undated care plan states:
-Problem: Resident removes oxygen nasal cannula at times. Nasal cannula placement closely monitored by staff with the following goal: resident to have maximum benefit of supplemental oxygen.
-Approach:
-Closely monitor oxygen nasal cannula to be on resident for oxygen saturation to be greater than 90 percent.
- Removes oxygen periodically by self.
- Check oxygen every shift, notify doctor if below 90%
-Problem: Resident is at risk for falls with Goal: Resident will not experience any injuries related to falls through the next review
-Approach:
-Fall mats to both sides of bed while resident is in bed
-Low Bed
-Refer me to therapy eval as indicated
-Resident uses a tilt and space wheelchair for all mobility and is dependent on
staff for mobility.
-Monitor positioning in chair and reposition as needed
-Keep in supervised area while up in chair
-Problem: Resident requires oxygen therapy as needed
-Goal: Resident will exhibit no shortness of breath through the next review
-Administer residents oxygen as ordered
-Ensure that resident's supply is available at all times
-Monitor for changes in resident's symptoms that may indicate worsening respiratory status
and report to physician
-Check oxygen saturations as ordered and if indicated
-In the event of a power outage provide oxygen as ordered with emergency tank
-Saturations every shift notify doctor if below ninety percent
-Problem: Resident requires assistance with splints/braces contractures both lower extremities
-Goal: Staff will apply splints/brace per therapy orders through the next review
-Approach:
-Assist resident with the application according to the scheduled wearing time
-Staff to provide passive range of motion
-Monitor resident skin under and around the device for irritation or break
down every shift
-Wash and dry residents hands and between fingers every shift
During a continuous observation on 12/5/22 from 2:31 P.M. to 4:00 P.M. showed:
-Nasal cannulas not in nose. Oxygen tubing laying across face with nasal cannulas resting on right check and tubing laying across the inside of resident's mouth. Additional tubing is draped across the left side of his/her cheek
-Oxygen concentrator set at 4 Liters
-He/she turning head back and forth against pillow
-His/her cheeks are red
-His/her tongue is thrusting at tubing in mouth
-He/she was not checked on by any staff member until 4:00 P.M. when LPN A was notified by state surveyor that oxygen nasal cannula was not in his/her nose.
-No fall mat observed in room and the bed was not in a low position.
During a continuous observation on 12/06/22 from 10:30 A.M. to 2:06 P.M. showed:
-Resident was not repositioned.
-Resident moved from dining room at 2:06 P.M. and wheeled down to bedroom.
-Resident is in tilt & space wheelchair completely dependant for repositioning by staff.
During a continuous observation on 12/6/22 from 8:48 A.M. to 2:13 P.M. showed:
-Resident #1 sitting up in tilt & space wheelchair
-He/she has not been repositioned or transferred out of his/her chair.
During an observation on 12/7/22 at 10:20 A.M. showed:
-Resident sitting in Med [NAME] chair in dining room not wearing palm protector, left hand splint, and no rolled wash cloth in palm of hand.
During an observation on 12/7/22 at 8:10 A.M. showed:
-Oxygen concentrator set at 4 liters.
During an observation on 12/8/22 at 8:14 A.M. showed:
-He/she is in dining room not wearing splint, rolled wash cloth, or elbow brace.
Record review on 12/7/22 at 8:47 AM of Treatment Records showed:
-Oxygen saturations recorded every shift
-Oxygen at 2 liters via nasal cannula to keep saturations greater than ninety as needed had no initials for the month of December
-Right elbow splint on while in wheelchair initialed for every shift 7-3 and 3-11
-Left hand palm protector to be worn at all times initialed for every shift for December
-May use rolled wash cloth as palm protector initialed for every shift for December
During an interview on 12/06/22 at 2:46 P.M. with CNA A said:
-He/she hooked Resident #1 up to oxygen and checked resident's brief.
-Resident #1 had voided of urine.
-He/she repositioned resident who had not been repositioned since he/she has been there today.
-Knows resident needs oxygen when his/her face gets red.
-Oxygen is usually applied to Resident #1 anytime he/she is in bed when she is laying down.
-He/she knows what specific cares to provide to resident based on observations and is not sure if there is a care plan he/she can look at.
During an interview on 12/7/22 at 3:50 P.M. with CNA C said:
-He/she knows resident's personal cares from resident's care plans
-He/she doesn't necessarily have time to review all care plans but would make time
-He/she is not sure of any residents with splints. When he/she was previously employed by facility Resident #1 use to have hand things but he/she is not sure if they continue to put them on him/her as they kept falling off when he/she would put them on her
-He/she knows to apply Resident #1's oxygen because they typically do it when Resident #1 lays down.
-Resident #1's oxygen is taken every shift
-Resident #1 may be able to wiggle oxygen tubing off but he/she has never seen him/her get oxygen tubing off unless it wasn't applied properly
-Resident #1's oxygen should be set at 2 liters
-Residents to have bed lowered include Resident #1
During an interview on 12/7/22 at 3:35 P.M. with LPN A said:
-Resident #1 receives oxygen when they lay him/her down
-Nurses check Resident #1's oxygen a minimum of one time per shift
-Resident #1's hand splints are applied in correlation with therapy. Nurses let therapy know if they need them and splints are stored in laundry.
-CNA's are to put splints on in the morning. There is a list located in the restorative aid book that should have directions
-Staff are aware how to provide specific cares to residents based on care plans they have available. He/she is not aware of information on resident specific cares being posted or available anywhere else for staff
During an interview on 12/8/22 at 8:47 A.M. with Physical Therapy Aid A said:
-Resident #1 is on hospice, we rely on nursing to keep up with splinting unless hospice changes order for any reason
-Resident #1 does have splints but not sure if hospice has changed that
-Right now there is no designated restorative aid for residents. Therapy does staff training then all nursing staff are responsible for needs being met for that resident. Nursing staff are instructed to notify therapy if the resident is getting better or has a decline
During an interview on 12/8/22 at 9:07 A.M. with CMT A said:
-Residents that have splints include Resident #1
-Resident #1 should be wearing splint but he/she has no idea where splint is located
-He/she can find resident specific care needs in residents care plans or LPN A also provides him/ her with updates or changes to resident's care plan
-Resident #1 has oxygen on while laying in bed and should be set at 2 liters
-He/she used to work as a restorative therapy aid but has no idea where he/she soul document restorative cares that therapy has directed nursing aids or certified nursing staff to provide
During an interview on 12/8/22 at 9:15 A.M. with CNA B said:
-He/she is not personally providing therapy to residents.
-He/she does not know where he/she would document therapy cares
-He/she has not seen residents wearing splints
-Resident #1 has oxygen stats checked all the time but he/she applies oxygen when Resident #1 is in bed or when her saturations are low
-Resident #1's oxygen should be set at a 2 or 3 but is not 100% sure
-Resident #1 will pull at nasal cannula tubing and take it off
-He/she knows residents likes and dislikes from resident care plans and observing resident body language. Some residents are able to communicate their preferences. He/she does not know of any resident specific resource outside of care plans.
During an interview on 12/08/22 at 08:57 A.M. the MDS/Care Plan nurse said:
-Been here a year.
-Responsible for care plans.
-Weekly care plan meeting with other departments involved.
-Been learning how approaches and goals need to be. Its been hard to catch up on everyone's care plans.
-Has been pulled for staffing needs and unable to get care plans caught up.
-Update care plans weekly with meeting.
-The care plan needs show how to take care of a resident and help with continuity of care.
-Insulin dependence, seizures, activities of daily living (ADLs), anticoagulants, dementia care, activities, and oxygen therapy even if its PRN should all be care planned.
-During the last month or so of the previous administrator care plan meetings did not happen and did not know why.
During an interview on 12/08/22 at 1:35 P.M. the Interim Director of Nursing said:
-The MDS nurse updates care plans.
-Care plans need to be about care; and is what drives care.
-He/she is aware that the care plans need to be updated.
-Seizures, Dementia care, anticoagulants, and ADL needs should all be care planned.
CONCERN
(E)
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 assure staff provided assistance to dependent residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure staff provided assistance to dependent residents with grooming and showers by failing to provide at least two showers a week to six residents (Resident #1, #30, #26, #7, #20, and #3). The facility also failed to provide shaving for one dependent resident (Resident #41). The facility census was 43.
Review of the facility's policy on Supporting Activities of Daily Living (ADL) Policy, March 2018, showed:
-Policy Statement: 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 will receive the services necessary to maintain good nutrition, grooming, and personal, and oral hygiene.
-Policy Interpretation and Implementation:
Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:
a. hygiene (bathing, dressing, grooming, and oral care)
b. mobility (transfer and ambulation, including walking)
c. elimination (toileting)
d. dining (meals and snacks), and
e. communication (speech, language, and any functional communication systems)
If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining
care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.
A resident's ability to perform ADLs will be measured using clinical tools, including the MDS.
1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/9/22 showed:
-Requires total assistance with bed mobility, transfer, eating, toilet use, dressing, and personal hygiene
-Always incontinent
-Diagnoses include seizure disorder or epilepsy, traumatic brain injury
Review of physician's orders dated December 2022 showed:
-Diagnoses of abnormal pelvis, hip, and spine, traumatic brain injury, chronic pain, muscle spasms, neuropathy (condition causing numbness or weakness), and constipation
-Right elbow splint on while up in wheel chair
-Left hand palm protector to be worn at all times except to wash hand or shower may use rolled wash cloth as palm protector for both hands
Review of care plan showed:
-Resident requires total assistance with Activities of Daily Living
-Two person assist resident with bathing
-One person to assist with all personal hygiene
-Two person assist with dressing and incontinent care
-2 person assist with all transfers using the full body lift
-2 person assist with bed mobility and repositioning
-1 person assist with locomotion in wheelchair/c
Observation on 12/5/22 at 2:43 P.M. showed:
-His/her hair disheveled, cheeks rosy, lips appear dry
Record review of shower schedule on 12/8/22 at 8:30 A.M. showed:
-Showers scheduled for Wednesday evening and Saturday evening
Record review of shower sheets showed:
-Shower received Friday 11/11/22
-Shower received Monday 11/14/22
-Shower received on Monday 11/21/22
-Shower received on Sunday 12/4/22
2. Review of Resident #30's MDS, dated [DATE], showed:
-Diagnoses of stroke
-He/she requires physical help in part of bathing activity.
-Resident requires partial/moderate assistance with showering/bathing self.
Review of resident's care plan showed:
-He/she requires assistance to complete daily activities of care safely
-Goal & Target date: Will maintain self care for 90 days as evidenced by continued ability to feed myself after set up, assisting with bathing my face and upper body
-Approaches included:
-Assist me with my hair
-Bathe me per schedule
During an observation on 12/5/22 at 11:56 A.M. showed:
-Resident in dining room with hair that was unbrushed or combed showing large flat areas on back of head where he/she had been laying.
During an observation on 12/8/22 at 11:08 A.M. showed:
-He/she walking down the hallway with disheveled hair that had not been brushed or combed
Record review of shower schedule showed:
-His/her scheduled shower days are Tuesdays and Fridays
Record review of shower logs showed:
-Shower refusal documented on Tuesday 11/1/22
-Shower received on Friday 11/10/22
-Shower received on Friday 11/18/22
-Showered received on Friday 11/23/22
-Shower received on Friday 12/2/22 and Tuesday 11/29/22
3. Review of Resident #26's MDS, dated [DATE], showed:
-Requires total dependence for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene, and bathing
-Resident is always incontinent of bowel and bladder
-Diagnosis of disorder of muscle weakness, idiopathic peripheral autonomic neuropathy (a condition of nerves that are damaged that affect the feet), bilateral primary osteoarthritis of knee (a painful degenerative condition that can reduce mobility and make daily tasks difficult to manage), cognitive communication deficit, and unspecified intellectual disabilities
During an observation on 12/8/22 at 8:41 A.M. showed Resident #26:
-He/she stated to CNA B 'I need a shower. Please get me a shower today'.
-CNA B told him/her 'we will get you one, your shower won't be until evening, you are an evening shower'
Record review of shower schedule book showed:
-Resident #26 shower days are Monday evening and Thursday evenings
Record review of shower logs showed:
-Received shower on Tuesday 11/8/22,
-Received shower on Monday 11/14/22
-Received shower on Tuesday 11/15/22
-Received shower on Monday 11/21/22
-Blank shower sheet in shower book dated 12/5/22 had no information written on it
4. Review of Resident #7's MDS, dated [DATE], showed:
-Diagnosis of cerebral infarction (a stroke) and Parkinson's disease
-Requires one person physical assistance with dressing, personal hygiene, and bathing
-Has Impairment on one side and uses a cane
-He/she is not steady but able to stabilize with human assistance in moving from seated to standing position, walking, moving on and off toilet
-He/she requires substantial/maximal assistance from staff for more than half the effort with toileting hygiene, shower/bathing self
During an observation on 12/6/22 at 8:20 A.M. showed:
-Hair going in all different directions at breakfast table
Record review of shower schedule showed:
-Scheduled shower days are Wednesday during the day and Saturday during the day
Record review of shower logs showed:
-Shower received on Sunday 11/13/22
-Shower received on Wednesday 11/23/22
-Shower received on Saturday 12/3/22
5. A review of Resident #20's quarterly MDS, dated [DATE], showed:
-Diagnosis of Alzheimer's disease and Depression,
-Resident requires limited assistance with personal hygiene and dressing with one person physical assistance
-Resident requires physical help in part of bathing and is dependent
Review of care plan showed:
-Problem onset: Resident resists cares at times, primarily showers
-Goal & Target date: Resident will shower as scheduled through next review
-Approaches:
-Resident prefers evening shower
-If resident refuses her shower re-approach at a different time
-Monitor and document resident's behavior
-Do not argue with resident
-Identify causes for behavior and reduce factors that may provoke resident
-Have another staff member approach resident when she continues to refuse
-Talk with resident in calm voice when behavior is disruptive
-Establish a rapport with resident prior to offering a shower
-Give resident choices, 'would you like to shower after you smoke / eat'
-Encourage family/responsible party to visit with resident
-Try phrases like 'it's time to take a shower' instead of 'would you like to take a shower'
-Handwritten note shows: 5/31/22 Refuses showers goal: shower once a week
-Resident needs supervision assistance from staff with ADL cares-Goal & Target Date: Resident will have her needs met with little supervision through the next review
-Approaches:
-Place resident's supplies on the bedside table within reach
-Give resident verbal cues to help prompt
-Praise resident when a grooming, bathing, or hygiene task is successfully completed
-Break resident's tasks up into smaller steps
-Resident frequently refuses showers, reapproach at a later time, or with different staff.
-Report to nurse if continues to refuse
-Resident prefers evening showers
Record review of shower schedule showed:
-Scheduled shower days are Monday evenings and Thursday evenings
Record review of shower logs showed:
-Shower received on Tuesday 11/8/22
-Shower received on Monday 11/21/22
-Shower received on Sunday 12/4/22
-No documented refusals
6. Review of Resident #3's quarterly MDS assessment, dated 11/17/22, showed:
-Diagnosis of muscle weakness, age-related osteoporosis with pathological fracture, atherosclerosis of native arteries of left leg with ulceration of other part of foot (a disease of peripheral blood vessels characterized by the narrowing and hardening of the arteries that supply the legs and feet)
-Requires substantial/maximal assistance with shower/bathing self, partial moderate assistance with toilet hygiene,
-Requires limited assistance with transfers and dressing by a one person physical assist
-Requires extensive assistance with toilet use by one person physical assist
-Uses a wheelchair
Review of care plan showed:
-Resident requires staff assistance for all ADL's at different levels
-Goal: Resident will be able to participate in part of ADL's through next review
-Approaches:
-One person to assist resident when bathing
During an observation on 12/7/22 at 2:34 P.M. showed:
-Resident #3 stopped Physical Therapy Assistant (PTA) A and said I want a shower, am I going to get one?
-PTA A responded he/she would let staff know
During an observation on 12/7/22 at 3:12 P.M. showed:
-Resident #3 stopped CNA A in hallway and asked 'When am I going to get my shower'
During an observation on 12/7/22 at 3:49 P.M. showed:
-Resident #3 expressed desire for shower
-CNA A told resident he/she promised to get him/her a shower before he/she leaves for the day
-Resident #3 said be sure you give me a bath, I have waited all day, you don't make promises you don't keep.
During an Interview on 12/7/22 at 3:53 P.M. with Resident #3 said:
-Last received shower over a week ago
-Suppose to receive showers two times a week and is not getting that
During an Interview on 12/8/22 at 8:16 A.M. with Resident #3 said:
-Did not get a shower yesterday
-Staff came in after 8:00 PM when he/she was already in bed and offered a shower then but advised staff he/she did not want one then because she/he was already in bed
-Was disgusted as he/she waited all day for a shower and even skipped the Christmas move activity as he/she was waiting on staff to come and get him/her for a bath
Record review of shower schedule showed:
-Scheduled shower days are Wednesday and Saturday during the day
Record review of shower logs showed:
-Shower received on Thursday 11/10/22
-Shower received on Wednesday 11/23/22
-Shower received on Monday 11/28/22
-Shower received on Saturday 12/3/22
Record review of shower schedule book showed:
-Note in shower book reads 'Please fill out all shower sheets each morning and leave those you don't get done in binder for following shifts to make up. Entirely too many showers are being missed. Thanks!'
During an Interview on 12/7/22 at 3:35 P.M. LPN A said:
-CNA's were responsible for daily showers
-Staff pull the daily shower sheets and turn them into him/her upon completion
During an Interview on 12/7/22 at 10:53 A.M. LPN A said:
-Shower logs were kept in a book but could not locate the book.
-He/she pulled out completed shower log sheets for December that had been completed but not yet filed from a black metal shelf in staff office
-He/she believes the office maintains shower logs from previous months
During an Interview on 12/8/22 at 9:07 A.M. CMT A said:
-Knows resident shower days based on shower book list that is kept updated
-He/she has hard time getting showers done but things seem to be getting better
-He/she was shower aide but there was not enough staff now to ensure all showers are done
During an Interview on 12/8/22 at 9:15 A.M. CNA B said:
-He/she has a list of shower schedules.
-Showers were getting completed twice per week.
-Some days were a struggle to get showers done. He/she usually has four showers in morning and four in evening.
7. Review of Resident #41's quarterly MDS dated [DATE], showed:
- A Brief Interview for Mental Status (BIMS) score of 99; which indicates a Staff Assessment for Mental Status to be conducted;
-No behaviors;
-Requires one staff assistance with transfers, dressing, toileting, and dressing;
-Requires staff to set up for bed mobility and eating;
-Active Diagnoses are high blood pressure, Dementia without behaviors, Diabetes Mellitus II, and acute kidney failure;
Observation on 12/5/22 at 11:52 A.M. of Resident #41, showed:
-He/she had chin hairs.
Observation on 12/6/22 at 2:13 P.M. showed:
-Resident #41 still has chin hairs.
Observation on 12/7/22 at 8:44 A.M. showed:
-Resident #41 still has chin hairs.
During an interview on 12/7/22 at 9:25 A.M. CMT A said:
-Shower days were when ladies get their chin shaved, but they often refuse.
During an interview on 12/7/22 at 9:34 A.M. LPN A said:
-Residents were shaved on shower days at least two times a week and as needed.
During an interview on 12/8/22 at 9:38 A.M. the Interim Director of Nursing (IDON) said:
-Residents should get shaved on shower days; it is part of their bathing hygiene.
During an interview on 12/8/22 at 12:14 P.M. the Administrator said:
-He/she expected everyone should be shaved every shower day or at least looked at daily for chin hairs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 provide meaningful activities, facility sponsored gro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide meaningful activities, facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This affected two sampled residents (Residents #12 and #41). The facility census was 43.
Review of facility policy, Activity Programs, dated June 2018, showed:
-The activities program is provided to support the well-being of residents and to encourage both independence and community interaction.
-Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.
-The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities.
-Activities are considered any endeavor, other than routine Activities of Daily Living (ADLs), in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health.
-Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.
-Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs.
-Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote:
a.
Self-esteem;
b.
Comfort;
c.
Pleasure;
d.
Education;
e.
Creativity;
f.
Success;
g.
Independence.
-Activities are not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents and family members may also provide the activities.
-All activities are documented in the resident's medical record.
-Activities participation for each resident is approved by the attending physician based on information in the resident's comprehensive assessment.
-Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board ( e.g., bed bound or visually impaired residents).
-Individualized and group activities are provided that:
a.
Reflect the schedules, choices and rights of the residents;
b.
Are offered at hours convenient to the residents, including evenings, holidays and weekends;
c.
Reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents;
d.
Appeal to men and women, as well as those of various age groups residing in the facility; and
e.
Incorporate family, visitor and resident ideas of desired appropriate activities.
-Residents are encouraged, but not required, to participate in scheduled activities.
1. Record review of activity progress notes dated 4/30/22, showed:
-Resident # 12 prefers to stay in his/her room.
-High anxiety, bad eye sight, loud noises irritate him/her.
-Resident #12 prefers to come out for Bingo on Monday and Fridays.
-He/she listens to his/her audio books daily while he/she crotchets.
-Resident #12 is always crying due to his/her anxiety.
Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/10/22, showed:
-Clear comprehension, usually understood with difficulty communicating some words or finishing thoughts, but is able to if prompted or given time
-Vision was moderately impaired - limited vision; not able to see newspapers headlines, but can identify objects
Review of physician's orders showed:
-Diagnoses includes anxiety, depression, and chronic headaches.
Review of resident's undated activity care plan showed:
-Resident has difficulty participating in usual daily routine due to her legal blindness and feeling down and depressed;
-Ask resident about activity preferences and help him/her plan;
-He/she prefers small group activities;
-He/she prefers to do activities on an individual basis;
-He/she likes activities that involve music;
-Remind the resident when activities are scheduled;
-Assist the resident to get to chosen activities;
-He/she enjoys spending time outside in fresh air.
During an observation on 12/6/22 at 8:32 A.M. showed:
-Resident #12 in his/her room and no activity provided.
-Activity staff passing out packets for coloring and activities in the dining room.
During an observation on 12/6/2022 at 1:58 P.M. showed:
-Activities staff going to only a select few rooms on 200 hallway including room asking some residents 'do you want to come do a craft? Staff did not invite Resident #12 to participate in an activity.
During an observation on 12/8/22 at 8:21 A.M. showed:
-Activities staff did not pass out activities calendars to all residents.
During an observation on 12/7/2022 at 8:47 A.M. showed:
-Activities staff passing out daily flyers with coloring pages to three residents in dining room and going down 200 hallway and going to only select resident rooms to pass out activity calendar pages. Staff did not go into Resident #12s room.
During an interview on 12/5/22 at 10:56 A.M. Resident #12 said:
-He/she wished they had more activities, he/she could not play cards or dominoes.
-Facility staff only had Bingo on Monday, Wednesday, and Friday.
-He/she has had recent trouble being able to read the Bingo cards and made staff aware. -He/she could not see the activity calendar due to changes in vision,
During an interview on 12/7/22 at 9:04 A.M. the Activities Aide said:
-He/she did not have time to complete activities with residents on both halls.
2. Review of Resident #41's quarterly MDS dated [DATE], showed:
- A BIMS score of 99; which indicates a Staff Assessment for Mental Status was conducted;
- Resident has short term and long term memory problems;
-No behaviors;
-Required one staff assistance with transfers, dressing, toileting, and dressing;
-Required staff to set up for bed mobility and eating;
Observation on 12/5/22 at 2:07 P.M. showed:
-No activity calendar posted on the unit or in the resident rooms;
-No activities being provided to residents on the special care unit;
Observation on 12/5/22 at 2:32 P.M. showed staff sitting in the dining room talking with each other, not engaged with residents; residents sat at the dining room tables with nothing in front of them.
Observation on 12/5/22 at 2:55 P.M. showed:
-No current activities going on.
Observation on 12/6/22 from 2:16 P.M. to 2:40 P.M. showed:
-Tea being offered in the dining room on the unit;
-A children's movie on the television, but no one was watching it;
-Staff were sitting in a corner of dining room talking amongst themselves;
Observation on 12/6/22 at 3:32 P.M. showed:
-There were no Activity calendars posted on the Dementia unit and were not placed in the resident's rooms.
Observation on 12/7/22 at 8:44 A.M. showed:
-The television was on, but residents were not watching it;
During an interview on 12/7/22 at 9:25 A.M. Certified Medication Technician (CMT) A said:
-The Activity Aide (AA) does not come onto the special care unit to do activities with the residents.
During an interview on 12/7/22 at 9:34 A.M. Licensed Practical Nurse (LPN) A said:
-He/she encouraged staff to do activities on the Dementia unit with the residents.
-Some of the same type activities were done on the secured unit as on the open community unit;
-Some residents come off of the unit to visit in the Cafe, which is the main dining room, for activities;
-Staff did not post activity calendars on the Dementia unit.
During an interview on 12/7/22 at 2:10 P.M. the Activity Aide said:
-He/she had not been on the Dementia Unit this week;
-He/she had been busy with decorating, shopping, and putting the big calendar up down the hall;
-When he/she did go over to the Dementia unit, she will do floor games, finger nails, and spa time;
-He/she sometimes brought residents off the unit for Bingo and Church.
-Residents with vision problems have audio books.
-Residents with hearing problems have picture books;
-If residents were having behaviors, he/she did not usually work with them, but went back later to try again;
-Sometimes he/she played music and flipped through a picture book for those that were non-verbal;
During an interview on 12/8/22 at 12:14 P.M. the Administrator said:
-He/she expected activities to occur at least once in the morning and once in the afternoon on all communities.
-For those with vision, hearing, or nonverbal disabilities, they should have a more personalized activity if the resident wished to participate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to ensure staff prepared foods in a form designed to meet each resident's individual needs when they did not ensure the pureed f...
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Based on record review, observation, and interview, the facility failed to ensure staff prepared foods in a form designed to meet each resident's individual needs when they did not ensure the pureed foods were of smooth consistency. This had the potential to affect all six residents on the pureed diet. The facility census was 43.
Review of the International Dysphagia (Some people with dysphagia have problems swallowing certain foods or liquids, while others can't swallow at all.) Diet Standardization Initiative (IDDSI), dated 2022, showed:
- The IDDSI Pureed level 4 (formerly known as Dysphagia Pureed) is designed for individuals who have moderate to severe dysphagia with poor oral phase abilities and decreased ability to protect their airway.
- The diet follows the regular diet planned with foods pureed which are of a smooth, homogenous and cohesive consistency.
- All foods to be served may be audited with standardized testing procedures including Fork Drip Test (used to check the correct thickness and cohesiveness in Levels 3-5 foods by assessing whether they flow through or how they hold together on the slots/prongs of a fork and comparing against the detailed descriptions of each level) and Spoon Tilt Test (used to determine the stickiness of foods (adhesiveness) and the ability of the food to hold together (cohesiveness).
Review of the daily menu showed items to be served include Ham, Brussels Sprouts and Scalloped Potatoes.
Review of the undated Brussels Sprouts pureed recipe showed one cup of Brussels Sprouts put in blender with ½ cup of butter and blend to puree consistency.
Observation on 12/7/22 at 11:30 A.M., showed [NAME] A put one cup of Brussels Sprouts in the blender with one cup of butter and blended it together to a runny consistency.
Observation on 12/7/22 at 12:30 P.M. of pureed hall test tray showed:
- Brussels sprouts - runny and soupy;
- Ham- chunky and gritty;
- Pureed peach cobbler-runny and tasted only of peaches not any of the crust or the spices in the crust;
During an interview on 12/7/22 at 1:40 P.M., [NAME] A said consistency of pureed foods should be like thick creamy yogurt. Most meats are difficult to puree correctly.
During an interview on 12/8/22 at 10:29 A.M., Registered Dietitian (RD) said she expected food that was pureed to be the consistency of pudding.
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 record review, observation, and interview, the facility failed ensure staff stored, prepared, distributed and served food to residents in accordance to professional standards for food service...
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Based on record review, observation, and interview, the facility failed ensure staff stored, prepared, distributed and served food to residents in accordance to professional standards for food service safety when they failed to label and date foods after opening, failed to ensure stored dishes were clean and free from dust and food particles, and failed to maintain kitchen tiles and ceiling in good repair and in a sanitary condition to prevent food contamination. This affects all residents who received food from the facility's kitchen. The facility census was 43.
Review of an undated Daily Aide Checklist showed:
- Properly date and label all items.
Review of an undated Daily [NAME] Checklist showed:
- All items in fridge properly labeled and dated;
- All dishes clean and put where they belong. Must be dry.
Observation on 12/5/22 at 9:25 A.M., showed:
- Food on the floor under a dish rack by the exit door;
- A yellow lid on the floor under the stove;
- A glass platter with dust and food particles on a shelf under the can opener;
- An open package of bacon in the refrigerator without a date or use by label;
- An open bag of waffles in the freezer without a use by date;
- A bag of frozen cookie dough unlabeled along with frozen chicken patties in the freezer;
- Three bowls on the floor under the bowl rack;
- Seasonings of white pepper, garlic powder, and sage, above the stove had their lids open;
- The seasoning containers were hot to the touch and slightly melted;
- An open raspberry Danish package without a date or label and not in a closed container;
- Ceiling above steam table was peeling;
- Floor tiles in front of the refrigerator broken or missing.
During an interview on 12/7/22 at 1:40 P.M., [NAME] A said staff should add the date they opened items as well as a use by date when they open it.
During an interview on 12/7/22 at 4:08 P.M., Dietary Manager (DM) said whoever opens the containers of food or seasonings should put the open date on it.
During an interview on 12/8/22 at 11:51 A.M., [NAME] B said:
- He/she does not know the process to put work orders in;
- He/she does not know the cleaning schedule;
- Staff should Clean pots, pans, and tubs are to remain open to air to dry, but with the opened portion facing up;
During an interview on 12/8/22 at 11:57 A.M., DM said:
- They have a cleaning schedule, but with it being him/her and [NAME] A only for so long that the cleaning schedules have not been taken care of;
- They have work order forms at the nurses' station and sometimes she just grabs maintenance to let him know about the problem.
- He/she had completed previous orders for some of the broken tiles and pests when her spouse worked in maintenance.
- Staff should allow pots and pans to air dry face down to keep dust and dirt from getting inside.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure nurse aides (NA) were certified within four months and failed to ensure nurse aides were in a state-approved training ...
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Based on observation, interview, and record review, the facility failed to ensure nurse aides (NA) were certified within four months and failed to ensure nurse aides were in a state-approved training program. Facility census was 43.
Review of facility policy, Nurse Aide Qualifications and Training Requirements, dated May 2019 showed:
-Nurse aides must undergo a state-approved training program.
-Facility will not employ any individual as a nurse aide for more than four months unless that individual is competent and has completed a training program or a program approved by the state.
-Facility will not employ any individual as a nurse aide for less than four months unless the individual is participating in a state-approved training program.
Review of the NA employee list showed:
-NA A employed since 10/2022.
-NA B employed since 10/2022.
-NA C employed since 10/2022.
-NA D employed since 07/2022.
-NA E employed since 05/2021.
-NA F employed since 11/2022.
During an interview on 12/5/22 at 9:37 A.M. the Interim Administrator, Interim Director of Nursing (DON), and DON said:
-Nurse aides are not certified within four months.
-Nurse aides should be certified within four months.
-They do not currently have certified nurse aide classes through the nursing home.
-They are working with another facility to get nurse aides into a class.
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 observation, interview, and record review, the facility failed to maintain an effective, comprehensive, data-driven QAPI program that focused on outcomes of care and quality of life when the ...
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Based on observation, interview, and record review, the facility failed to maintain an effective, comprehensive, data-driven QAPI program that focused on outcomes of care and quality of life when the facility failed to provide documentation and evidence of its ongoing Quality assurance and performance improvement (QAPI) program. Facility census was 43.
Review of the facility QAPI plan showed:
-Meet monthly.
During the entrance conference interview on 12/5/22 at 9:37 A.M., the Interim Administrator said:
-He/she started in November 2022.
-He/she could not find any QAPI documentation for 2022 and only one meeting for 2021.
-QAPI is monthly.
During a follow up interview on 12/08/22 at 11:56 A.M. the Interim Administrator was not able to provide any documentation from 2021.
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** Based on record review and interview, the facility failed to implement their water management policy and procedures to reduce th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia and did not review it annually. The facility also failed to ensure facility staff were informed on the facility's Water Management Plan. The facility was 43.
Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed:
-Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
-The facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the Center for Disease Control and Prevention (CDC) toolkit.
1. Review of the facility's Water Management Plan showed the following:
- Dated as produced April 2019, last reviewed April 2021;
- Action Plan- This plan will be reviewed annually by the Administrator, Director of Nursing, Infection Control Nurse and Maintenance Director;
- Records of regular monitoring, services and maintenance will be kept at the back of this plan. This is the responsibility of the facility Maintenance Director;
- Routine Control Actions included:
o Who facility- Risk assessment- Every two years;
o Shower and Spray Outlets- Weekly;
o Hot and Cold-Water Outlets- Weekly
o Water Heaters- Monthly/Annually.
Review of the facility's Legionella Monitoring records showed:
- Weekly Monitoring- September through November did not have any records of Legionella Monitoring;
- Monthly/Quarterly/Annual- No records found.
During an interview on 12/7/22 at 3:20 P.M., the Interim Administrator said:
- She started at the facility as the Interim Administrator in November. She did not know where the water management plan was or what the facility was doing for monitoring.
During an interview on 12/7/22 at 3:20 P.M., the Interim Director of Nursing/Infection Control Preventionist said:
- The facility had not had any cases of Legionellosis since the last certification process.
During an interview on 12/07/22 at 3:20 P.M., the Maintenance Director said:
- He worked at the facility about three years ago and he just came back in November;
- The Water Management Plan got brought up in a staff meeting 6 years ago so he called American Water to see what needed to be done, but they did not know what he was talking about. Then he called the county Health Department and was told it was not a concern;
- He does a weekly flushing of drains and toilets in areas and makes sure there is not any standing water anywhere.
- The EP book did not reflect any information regarding legionella.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0849
(Tag F0849)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure that resident's written plan of care included both the most recent hospice (end of life care) plan of care and a descr...
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Based on observation, interview, and record review, the facility failed to ensure that resident's written plan of care included both the most recent hospice (end of life care) plan of care and a description of the services furnished by the long term care (LTC) facility and the services furnished by Hospice for one sampled resident (Resident #1). The facility census was 43.
Review of facility hospice program policy showed:
-When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current staff
-All hospice services are provided under contractual arrangement. Complete details outlining the responsibilities of the facility and the hospice agency are contained in this agreement.
Review of the hospice service agreement, dated 12/21/20__ (blank line with no year filled in) showed:
The plan of care must reflect hospice patient and family goals and interventions based on the problems identified in the hospice patient assessment. The plan of care will reflect the participation of the hospice, facility, and the hospice patient and family to extent possible. Specifically, the plan of care includes:
-An identification of the hospice services, including interventions for pain management and symptom relief, needed to meet such Hospice Patient's needs and the related needs of Hospice Patient's family
-A detailed statement of the scope and frequency of such Hospice services
-Measurable outcomes anticipated from implementing and coordinating the Plan of Care
-Drugs and treatment necessary to meet the needs of Hospice Patient
-The Plan of Care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care
Coordination of Care:
-General: Facility shall participate in any meetings, when requested, for the coordination, supervision, and evaluation by Hospice of the provision of Facility Services. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hour per day.
Records:
-Creation and Maintenance of Record: Each clinical record shall completely, promptly, and accurately document all services provided to, and events concerning, each hospice Patient, including evaluations, treatments, progress notes, authorizations to admission to Hospice and/or Facility, physician orders entered
1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/9/22 showed:
-Total dependence in bed mobility, transfers, eating, toilet use, dressing, and personal hygiene
-Unable to complete Brief Interview for Mental Status (BIMS), assessment used to determine resident's cognitive status)
Review of resident's current physicians orders, dated December 2022, showed:
-Order for Hospice
-Diagnoses of dysphagia (difficulty or discomfort in swallowing) , seizure disorder, abnormal pelvis, hip, spine, traumatic brain injury, chronic pain, muscle spasms, neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness), and constipation
Review of resident's current care plan, dated 11/23/2021, showed:
-His/her care will be coordinated between Hospice and the facility.
-Hospice nurse visits two times per week,
-Hospice aide visits two times per week.
-Resident will have additional cares by hospice services;
-Visits by hospice RN and hospice aides;
-Resident requires total staff assistance for all ADL's.
- He/she is non-ambulatory.
-Care plan shows no specific cares provided by facility verses by hospice staff including shower days.
Observation on 12/8/22 at 11:00 A.M. showed:
-Two hospice staff exit Resident #1's room after providing services and exited the building. The staff did not stop to speak about the resident to any staff member or document in any book prior to leaving.
Observation and record review of hospice book on 12/8/22 at 12:05 P.M. showed:
-No documented services provided in December.
-Visit on 11/30/22 at 9:00 AM, no documentation of services provided during visit
-Visit on 11/21/22 at 8:00 AM, no documentation of services provided during visit
-Visit 11/14/22 at 10:30 AM, no documentation of services provided during visit
-Visit on 11/10/22 at 6:45 PM by home health aid for a bath
-Visit on 11/8/22 at 6:45 PM by home health aid for a bath
-Visit on 11/1/22 (no time) documented by Licensed Practical Nurse (LPN) for Skilled Nursing Visit
-Visit on 11/1/22 at 6:45 PM by home health aid for a bath
-Hospice Aide Visit Assignment was made 11/22/21
During an interview on 12/7/22 at 3:35 P.M. with LPN A said:
-Hospice residents were scheduled to receive showers on days other than Tuesdays or Thursdays due to hospice staff coming in on Tuesdays and Thursdays.
-Each hospice resident has a charting book on a shelf in the nurse aid office.
During an interview on 12/8/22 at 8:47 A.M. with Physical Therapy Aid A said:
-Resident #1 was on hospice.
-Therapy staff relied on nursing to keep up with splinting of resident #1's hands unless hospice changed that order for any reason.
-He/she was unsure if hospice any orders.
During an interview on 12/8/22 11:55 A.M. LPN A said:
-He/she was the team member who coordinates with hospice.
-Hospice staff were in the facility to see residents today.
-He/she observed two hospice aides but has not seen the hospice nurse today
-He/she got hospice updates when hospice staff came into the facility.
-The hospice nurse usually comes in twice a week but it depended on resident and where they were at in their level of care needs and stages of death. If a resident was nearing death, hospice staff could be here 24 hours hrs a day or come in hourly.
-He/she did not have any contact with hospice today while they were in the facility.
-Hospice staff documents separately in their hospice books. The hospice staff who were here today have their own books.
-He/she said a usual scenario with hospice coordination was hospice would come in and see each hospice resident and then they would come up to him/her and let him/her know of any skin issues and also notify their nurse on the hospice team.
-He/she thinks hospice aides communicate with hospice nurse via work cell phones.
During an interview on 12/8/22 at 3:42 P.M. with Facility Administrator said:
-He/she believed facility social services was the facility hospice liaison and the Director of Nursing would have to be involved with residents receiving hospice care.
-Hospice care/services should be documented in hospice books in the nursing office.
-Hospice should be communicating with charge nurses when they get to the facility by asking what was going on with the resident and then when they leave giving an update of what they did
-His/her expectation would be for hospice to communicate when coming in and going out of the facility.
Sept 2019
9 deficiencies
CONCERN
(D)
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 ensure staff provided written notices of transfer or discharge to resident and their representative including the reasons for the transfer ...
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Based on interview and record review, the facility failed to ensure staff provided written notices of transfer or discharge to resident and their representative including the reasons for the transfer and in a language they understood. This affected one of 14 sampled residents (Residents #1). The facility census was 46.
1. Review of Resident #1's medical record showed:
- Facility staff documented a physician order dated 7/8/19 to send the resident to an area hospital by ambulance;
- Facility staff documented a physician order dated 8/9/19 to send the resident to an area hospital by ambulance for evaluation and treatment;
- No evidence of written notices of transfer for the resident or responsible party for either transfer.
During an interview on 9/20/19 at 10:01 A.M., the Social Service Designee (SSD) said:
- He/she had not known the nurses sent the resident out on those days;
- The nurses gave a night nurse report to the bookkeeper who gave a copy to the SSD. He/she found out from that report who the nurses sent out and then he/she mailed a letter of discharge or transfer to the residents responsible party.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record review, the facility failed to ensure staff followed professional standards of care when staff failed to follow facility policy and manufacturer's guidelin...
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Based on observations, interviews and record review, the facility failed to ensure staff followed professional standards of care when staff failed to follow facility policy and manufacturer's guidelines when they administered Resident #143's inhaler and did not have a pharmacist identify Resident #193's bottles of medication the resident brought to the facility upon admission. The facility census was 62.
1. Review of the manufacturer's guideline For the Flovent HFA inhaler showed:
- After you have breathed in completely all the spray, close your mouth and hold your breath for ten seconds, or as long as is comfortable;
- Breathe out slowly as long as you can;
- Wait about 30 seconds and shake the inhaler well for five seconds;
- Repeat inhalation for second puff.
Review of the facility policy for Administering Medications through a Metered Dose Inhaler, revised 2010, showed:
- Shake the inhaler gently to mix the medication with aerosol propellant;
- Ask the resident to inhale and exhale deeply for a few breath cycles. On the last cycle, instruct the resident to exhale deeply;
- After administration of medication, instruct the resident to inhale deeply and hold breath for several seconds;
- Remove the mouthpiece and instruct the resident to exhale slowly through pursed lips;
- Repeat inhalation, if ordered. Allow at least one minute between inhalations of the same medication.
2. Review of Resident #143's current physician order sheet POS dated 9/12/19, showed the physician ordered Flovent HFA inhaler 110 mcg (micrograms) two puffs twice a day.
Observation on 9/19/19 at 10:08 A.M., showed Certified Medication Technician (CMT) A administered the resident's inhaler in the following way:
- Shook the inhaler;
- Only instructed the resident to exhale, placed the inhaler in the resident's mouth and depressed the canister;
- The resident held his/her breath less than five seconds;
- Without shaking the canister, CMT A immediately administered the second puff and removed the inhaler from the resident's mouth;
- The resident immediately reached for a glass of water to rinse his/her mouth.
During an interview on 9/19/19 at 3:45 P.M., the Director of Nurses said she expected staff to follow manufacturer's guidelines when administering inhalers.
3. Review of the facility's undated partial (pages 1-4) policy for Pharmaceutical Services did not address medications brought in to the facility on admission.
4. Observation and interview on 9/19/19 at 10:00 A.M., of the CMT's 200 hall medication cart showed five opened bottles of Resident #143's medications that were not dated when opened. There was a bottle with Tramadol (narcotic-like pain reliever) tablets and a bottle with oxycodone (pain reliever for moderate to severe pain) tablets in them.
CMT A said :
- This is medication brought in with the resident from another facility;
- The medications new residents brought in on admission were not checked by a pharmacist;
- If the resident had an order for the medication, staff administered the medication from the bottles they brought in to the facility;
During an interview on 9/19/19 at 3:45 P.M., the Director of Nurses said:
- Per facility policy if medication is brought in by the family or from another facility, we should have the medications identified by a pharmacist or physician;
- She was not aware staff did not get medications brought in with the resident identified by a pharmacist or physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 staff obtained the appropriate documentation and signatures ...
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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 staff obtained the appropriate documentation and signatures related to residents' advance directives (Indicates health care wishes, such as whether or not a resident wants CPR-cardiopulmonary resuscitation-and authorization of an agent to make health care decisions for the resident). This affected six out of 14 sampled residents (Residents #2, #36, #38, #1, #5 and #143). The facility census was 46.
Review of the facility's undated policy related to advance directives, showed:
-Prior to, or at the time of admission, the staff member doing the admission will ask residents, and/or their family members about the existence of any advance directives and will provide them with written information regarding their rights under state law to accept or refuse medical treatment.
-Should the resident indicate he he or she has issued advance directives about his or her care and treatment, the facility will require that a copy of such directives be included in the medical record.
-The care plan team will review advance directives annually with the resident to ensure they are still the wishes of the resident.
-Changes or revocations must be submitted to the facility in writing.
-The facility will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical records and plan of care.
-Inquiries concerning advance directives should be referred to the administrator and/or the director of nursing services.
1. Review of Resident #2's Letters of Conservatorship, dated [DATE], showed a public administrator (PA) was named for the resident.
Review of the resident's Outside of Hospital Do Not Resuscitate Order (OHDNR-indicates to not perform CPR if the heart stops beating or breathing stops), dated [DATE], showed:
-Signature of the PA;
-Signature of two witnesses;
-No physician signature.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:
-Unable to speak;
-Long- and short-term memory problems;
-Severely impaired decision-making skills;
-Diagnoses included traumatic brain injury.
Review of the resident's [DATE] physician order sheet (POS) showed the resident's code status was DNR.
During an interview on [DATE] at 2:47 P.M., the Social Services Designee (SSD) said he/she had not realized that the physician did not sign the OHDNR form. The administrator said staff should have found this during annual reviews of advance directives.
2. Review of Resident #36's advance directive information showed:
-A durable power of attorney (DPOA) form, which included health care, dated [DATE], named a DPOA agent to make health care decisions for him/her;
-An OHDNR signed by the DPOA agent and physician on [DATE];
-Verification of incapacity form, signed by one physician on [DATE], and the second physician on [DATE], three years after the agent signed the OHDNR.
Review of the resident's MDS for a significant change, dated [DATE], showed:
-Severe cognitive impairment;
-Diagnoses that included Alzheimer's disease.
During an interview on [DATE] at 2:47 P.M., the SSD said that a while back, staff realized that several residents needed verifications of incapacity, so they obtained them. He/she did not realize they should have had the OHDNR's re-signed.
3. Review of Resident #38's medical records showed;
-A financial durable power of attorney, dated [DATE], which named a DPOA agent to make financial decisions;
- An OHDNR signed by the financial DPOA agent on [DATE] and the physician on [DATE];
-No health care DPOA form in the records.
The resident's [DATE] POS showed the resident's code status was DNR.
Review of the resident's admission MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-A diagnosis of dementia.
During interviews on [DATE], at 2:36 P.M. and [DATE] at 2:47 P.M., the SSD said he/she:
-Only had the financial DPOA form on the chart;
-Received the resident from another facility, knew there was a signed DNR, a DPOA, and verification of incapacity, but did not realize the DPOA was not for health care;
-Planned to contact the DPOA to determine if a DPOA form for health care existed.
4. Review of Resident #1's MDS, dated [DATE], showed:
- Imp[aired decision making skills;
Diagnoses of Alzheimer's Disease and depression.
Review of the resident's medical record showed:
- The resident appointed his/her spouse as the durable power of attorney DPOA, on [DATE];
- The resident's spouse signed an outside the hospital do not resuscitate (OHDNR) form on [DATE];
- The physician's signatures on the incapacitation form were dated as signed on [DATE] and [DATE].
5. Review of Resident #5's MDS, dated [DATE], showed:
- Impaired decision making skills;
- Diagnoses of Alzheimer's disease, anxiety and depression.
Review of the resident's medical record showed:
- Resident appointed his/her daughter as the DPOA;
- Resident's daughter signed the OHDNR on [DATE];
- The physician's signatures on the incapacitation form were dated [DATE] and [DATE].
During an interview on [DATE] at 10:42 A.M., the social services designee (SSD) said:
- The resident's daughter lived out of state;
- Because the daughter lived out of state, he/she went ahead and had the daughter sign the OHDNR before the physicians signed the incapacitation form.
6. Review of Resident #143's MDS, dated [DATE], showed:
- Moderately impaired decision making skills;
- Diagnoses of dementia and Parkinson's disease.
Review of the resident's medical record showed:
- The resident appointed his/her daughter as his/her agent DPOA;
- The OHDNR was signed by the daughter on [DATE];
- There were no signed incapacitation forms in the medical record.
During an interview on [DATE] at 10:5 A.M., the SSD said:
- The resident transferred from a different facility and the DPOA paperwork and the OHDNR was sent to the facility from the resident's previous facility;
- He/she had not realized there was no signed incapacitation forms in the medical record;
- He/she had several admissions that same week and forgot to go back and check the incapacitation forms were in place.
During an interview on [DATE] at 11:07 A.M., the DON said:
-The purple DNR sheet should be in the front of the chart for residents who want to be a DNR.
-The DNR should be appropriately signed by the resident/responsible person and the physician.
-Staff should check advance directive paperwork to ensure DNR forms are valid.
-Verification of incapacity, if required, should be done before the DPOA signs a DNR.
-DPOA's, DNR's and verifications of incapacity should be on residents' charts.
CONCERN
(E)
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 staff provided complete incontinent care, assis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided complete incontinent care, assisted a dependent resident with meals, and provided nail care. This affected two out of 14 sampled residents (Residents #6 and #1). The facility census was 46.
1. Review of the facility's undated policy related to perineal care showed:
-Clean resident front to back.
-Cleanse all areas of the genitals, including under and between all skin folds.
-Remove gloves, wash hands and apply new gloves.
-Turn the resident on his/her side and cleanse the buttocks and rectal areas.
-Remove gloves, wash hands and apply new gloves.
2. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/19, showed:
-Required extensive assistance for all care;
-Always incontinent of bowel and bladder.
Review of the resident's care plan, last updated on 8/21/19, showed:
-Required assistance for all care;
-Always incontinent of bowel and bladder;
-Provide perineal cleansing as needed.
Observation on 9/17/19 at 6:43 A.M., showed Certified Nurse Aide (CNA) A and Licensed Practical Nurse (LPN) A provided care for the resident in the following manner as the resident lay in bed:
-Both staff washed hands and put on gloves.
-CNA A handed LPN A moist wipes and LPN A cleansed each groin, but did not cleanse under and between all skin folds, and did not cleanse the complete genital area.
-Staff turned the resident to his/her side and LPN A cleansed a small amount of fecal material from the backside, helped put pants on the resident, opened a drawer, obtained socks and put them on the resident, then removed his/her gloves and washed his/her hands.
During an interview on 9/20/19 at 10:52 A.M., LPN A said staff should cleanse all areas of the genitals, including under and between skin folds.
During an interview on 9/20/19 at 11:07 A.M., the Director of Nurses (DON) said:
-Staff should cleanse all areas touched by urine or fecal material.
-Staff should cleanse all genital areas, including under and between skin folds.
3. Review of the facility's policy on Care of Fingernails, revised 2/18, showed:
- To clean the nail bed, to keep the nails trimmed and to prevent infection;
- Nail care includes daily cleaning and regular trimming;
- Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin.
Review of the facility's police on Assistance with Meals, revised 7/17, showed:
- Residents shall receive assistance with meals in a manner that meets the individual needs of each resident;
- Facility staff will help residents who require assistance with eating.
4. Review of Resident #1's care plan dated 9/25/17, showed:
- Resident has difficulty understanding others.
- Speak to the resident in a low, clear voice to increase chance of hearing;
- Resident needs you to speak directly in front of him/her to increase chance of hearing;
- Resident has impaired vision. Make sure resident's glasses are clean and available at all times;
- Provide set up assistance such as identifying food;
- Resident has poor safety awareness and poor eye sight;
- Monitor for changes in resident's condition that may warrant increased supervision/assistance and notify the physician;
- Potential for weight loss;
- Monitor resident's nutritional intake;
- Observe the resident for changes in appetite;
- Encourage resident to eat;
- Observe the resident while eating meals;
- Offer an alternative if meal refused or less than 50% of meal consumed;
- Requires assistance of staff to complete activities of daily living safely;
- Bathe me per schedule.
Review of the resident's MDS, dated [DATE], showed:
- Impaired daily decision making skills;
- Required extensive assistance of staff with eating and personal hygiene;
- Dependent on staff for bathing;
- Weight 213 pounds
- Diagnoses of Alzheimer's disease and diabetes mellitus.
Observation on all days of the survey 9/17, 9/18, 9/19 and 9/20/19 showed the resident did not wear glasses throughout the day. The resident had long fingernails greater than 1/8th inch long. Observation on 9/18, 9/19, and 9/20/19 showed the resident had a brown substance caked under the first and third fingernails on the left hand and under the first, second and third fingernails of the right hand.
Observation on 9/17/10 at 12:19 P.M., showed the resident sat at a round table with four other residents. The resident sat with his/her plate in front of him/her not eating, no staff assisted the resident. Continued observation up to 12:32 P.M., showed the resident sat at the table with his/her plate in front of him/her but not eating, no staff assisted the resident. At 12:32 P.M., the resident got up and walked back to his/her room. A staff member left the dining area to assist the resident back to his/her room. The resident's family member met the nurse in the hallway questioned the resident's finger stick reading, if staff gave the resident insulin before lunch and if the resident had eaten. The family member requested the residents plate of food, took it to the resident's room and assisted the resident to eat.
During an interview on 9/17/19 at 1:41 P.M., Family Member A said:
- He/she was at the facility over the weekend, only one CNA worked the Alzheimer's unit;
- Staff had not clipped or cleaned the resident's fingernails. The resident's nails were longer than he/she had ever seen them;
- He/she did not know if the resident had lost weight. His/her sibling and the resident's spouse brought in food for the resident and assisted him/her to eat it;
- He/she did not feel staff spent enough time to get the resident to eat. The resident was diabetic and after they gave him/her the insulin if he/she did not eat, his/her blood sugar plummeted usually between 2:00 and 4:00 P.M.
- The facility had sent the resident, more than twice, to the local hospital after he had become unresponsive for them to get his/her blood sugar reading back up.
Observation on 9/18/19 from 12:10 P.M., through 12:36 P.M., the resident sat at his/her dining table with his/her head hung down, his/her plate in front of him/her, the food untouched. At 12:14 P.M. staff asked the resident to take a drink of milk because he/she had received insulin. The resident took a drink and set the glass down. Staff did not assist or instruct the resident to eat. At 12:29 P.M., staff again asked the resident to take a drink of milk, did not offer to assist the resident to eat. At 12:36 P.M., the resident asked to go back to his/her room.
During an interview on 9/19/19 at 8:41 A.M., CNA C said:
- Staff should clean fingernails whenever they needed it and on shower days;
- Staff watched the residents on the Alzheimer's unit because some did not eat or drink as much as they should so staff watched them and if they did not eat then staff assisted them to eat;
- Sometimes Resident #1 got upset if staff tried to help him/her to eat.
During an interview on 9/20/19 at 11:07 A.M., the Director of Nurses said:
-By observation, staff should assist or offer to assist the resident to eat if they saw the resident not eating;
- Staff should offer the resident's not eating a substitute to see if they would like the alternate better;
- Some resident sat longer at the meal table without eating, if a resident sat for 10 to 15 minutes staff should have been offering to assist them with eating,
- Staff should provide nail care with the resident's showers and any other time if needed;
- Charge nurses should trim fingernails of diabetic residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 staff provided catheter (a sterile tube inserte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent urinary tract infections (UTI), or the possibility of developing them. This affected three out of 14 sampled residents (Residents #16, #143 and #145). The facility census was 46.
Review of the facility's September 2014 policy related to catheter care showed:
-The purpose is to prevent catheter-associated urinary tract infections.
-The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.
-Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag.
-Avoid splashing and prevent contact of the drainage spigot with the nonsterile container when emptying the drainage bag.
-Be sure the catheter tubing and drainage bag are kept off the floor.
-Cleanse the genital area with a washcloth, warm water and soap, using one area of the cloth for each downward, cleansing stroke.
-Rinse the area with a clean washcloth and warm water, using the same technique.
-Use a clean washcloth with warm water and soap to cleanse and rinse the catheter tubing from the insertion site to approximately four inches outward.
1. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/19, showed:
-Had a urinary catheter;
-Required extensive assistance with transfers, toilet use and personal hygiene.
Observation on 9/17/19 at 7:15 A.M. showed the resident lay in bed with his/her catheter in a cloth privacy bag, which laid on the floor.
During an interview on 9/19/19 at 2:10 P.M. Certified Nurse Aide (CNA) A said catheter and privacy bags and tubing should never touch the floor.
Observation on 9/19/19 at 3:00 P.M. showed the resident sat in his/her wheelchair near the nurses' station where several staff stood. His/her catheter bag was in a privacy bag which dragged on the floor.
Observation on 9/19/19 at 3:14 P.M. showed the resident self propelled him/herself down the 200 hall and his/her catheter privacy bag dragged on the floor as he/she moved down the hall.
Observation on 9/20/19 at 1:42 P.M. showed the resident self propelled his/her wheelchair in the hall near the administrative offices and his/her catheter privacy bag and approximately two inches of catheter tubing dragged on the floor as he/she moved down the hall.
2. Review of Resident #145's MDS, dated [DATE], showed:
- Difficulty with decisions making skills;
- Required assist with staff for toilet use and personal hygiene;
- Occasionally incontinent of bowel and bladder;
- Diagnoses of Schizophrenia and diabetes mellitus.
Review of the resident's laboratory urinalysis report, dated 8/3/19, showed bacteria consistent with a urinary tract infection.
Review of the resident's undated care plan, showed:
- Resident requires assistance with toilet use;
- Requires assist of one to the toilet;
- Assist resident adjust clothes;
- Observe for cloudy urine, foul odor, increased frequency or urgency;
- Assist me with good perineal hygiene.
Care plan is not update with Foley catheter use and care needs.
Review of the resident's current physician order sheet (POS), dated 9/5/19, showed:
- Foley catheter care every shift;
- Change Foley catheter every month and as needed size 16 french for urinary retention.
Observation on 9/17/19 at 7:15 A.M., showed the resident sat in his/her recliner, his/her catheter drainage bag lay on the floor. CNA C provided catheter care and got the resident ready for breakfast in the following way:
- Picked up the catheter drainage bag and placed in a dignity bag;
- Tied the dignity bag on to the resident's bed rail, the bottom of the dignity bag at on the floor;
- Removed the drainage bag from the dignity bag and drained the urine into a graduate;
- The draining spout lay against the side of the graduate, CNA C did not clean the spout before he/she placed the drainage spout back in the holder on the drainage bag;
- Removed the resident's underwear and replaced them with a disposable brief. He/she did not provide any peri care or clean the catheter tubing;
- Finished dressing the resident and assisted the resident into his/her wheelchair.
Observation on 9/17/19 at 11:58 A.M., showed LPN B pushed the resident from dining room down the hallway towards his/her room, the dignity bag drug the floor. At 12:06 P.M., the resident rolled self back in to dining room, the dignity bag dragged the floor.
Observation on 9/19/19 at 8:31 A,M., showed the resident sat in his/her wheelchair in the hallway. The resident's sock foot sat on top of the tubing which lay on the floor.
During an interview on 9/20/19 at 8:41 A.M., CNA C said:
- Catheter drainage bag, tubing and the dignity bag should not touch the floor;
- He/she should have cleaned the drainage spout with an alcohol pad after he/she drained the urine;
- He/ she should have provided peri care and cleaned the tubing.
3. Review of Resident #143's MDS, dated [DATE], showed:
- Difficult with daily decision making;
- Required extensive assist of staff with toilet use and personal hygiene;
- Indwelling catheter and always incontinent of bowel.
Review of the resident's care plan, dated 9/18/19, showed:
- Ongoing assessment of color, clarity and character of resident's urine;
- Ongoing assessment of resident for symptoms of urinary tract infection;
- Catheter care for resident every shift.
Observation on 9/17/19 at 7:10 A.M., and 11:33 A.M. showed the resident lay in bed with the catheter drainage bag in a dignity bag lay on the floor.
Observation on 9/19/19 at 9:15 A.M., showed the resident lay in bed on an incontinent pad with a brown circle of loose watery fecal matter. CNA B and CNA D provided incontinent and catheter care in the following way:
- Staff rolled the resident to his/her right side and cleaned the resident's buttocks;
- Rolled the resident to the left side, did not clean the right outer buttock or hip area that lay on the brown ring;
- Staff rolled the resident onto his/her back and completed peri care to the residents peri area;
- CNA B grasped the tubing about four to five inches from the insertion site and wiped down the tubing with a wash cloth;
- When staff put the brief and pants on the resident, CNA D held the drainage bag almost shoulder high above the resident's bladder before he/she thread it through the pant legs.
During an interview on 9/19/19 at 2:12 P.M., CNA B said:
- He/she should cleanse all areas of skin that urine and feces touched;
- He/she should anchor the catheter tubing as close to the body as possible when he/she cleaned it;
- The catheter drainage bag should be maintained below the bladder and should not touch the floor.
During an interview on 9/19/19 at 2:20 P.M., CNA D said:
- He/she should not raise the urinary drainage bag above the level of the bladder;
- The catheter drainage bag, dignity bag and tubing should not touch the floor.
4. During an interview on 9/20/19 at 11:07 A.M., the Director of Nurses said:
- Catheter and privacy bags should not be on the floor.
- Staff should cleanse the catheter bag drain spout with alcohol when they empty the bag.
- The catheter bag should remain below the level of the bladder.
- Staff should secure the catheter tubing as close to the body as possible during care to prevent pulling the catheter out of the body.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a group resident interview, attended by four residents, on 9/18/19 at 10:03 A.M., residents said:
-They have waited up...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a group resident interview, attended by four residents, on 9/18/19 at 10:03 A.M., residents said:
-They have waited up to 30 minutes for staff to answer call lights.
-One resident was incontinent due to the long wait for staff to answer his/her call light.
-Sometimes there is not enough staff to provide care.
-Their main concern was keeping staff and having staff they knew.
-Staff do not offer evening snacks room to room. Staff leave the snacks in the main dining room and residents have to go get them, if they want them.
-Residents felt bad for those who could not get a snack for themselves.
-Fridays and night shifts are times when there were fewer staff, and this was when most call light and care issues occurred.
3. During an interview on 9/20/19 at 1:51 P.M., the DON said:
-They try to keep consistent staffing, especially on the dementia unit.
-She was instructed that the allotted budget for nursing staff included two Certified Nurse Aides (CNA's) per hall, a Certified Medication Technician (CMT) and a licensed nurse for the day and evening shifts, and two CNA's and a license nurse for the building for night shift.
-If she felt more staff was required, she would discuss it with the administrator, then the administrator would need to obtain approval from corporate.
-When they have staff call in, they go down the staffing list, calling staff to try to find someone to fill the position.
-If they are unable to find someone, then the DON, the administrator or the MDS (Minimum Data Set) coordinator work the floor.
-They have had the CMT work as a CNA and had the nurse do his/her job, plus pass the medications, when needed.
Based on observations, interviews and record review, staff failed to provide consistent and competent care and services when staff failed to offer bedtime snacks to all residents and failed to provide oversight and assistance to enhance the dining experience during mealtimes on the unit. Twenty two residents lived on the unit. The facility census was 46.
Review of the facility's Assistance with Meals, revised 7/17, showed:
- Facility staff will serve resident trays and will help residents who require assistance with eating.
1. Observation on 9/17/19 at 8:18 A.M., of the breakfast meal showed:
- Two Certified Nurse Aides (CNAs) assisted residents into the unit dining room and to their chairs, at times having to move other residents in order to get the residents where they needed to sit;
- Delivered drinks and trays to the residents at the tables;
- Was in and out of the dining room to assist more residents into the dining room;
- Two staff sat at tables assisting some residents to eat, while others not eating, did not receive assistance.
- A visiting family member assisted two residents to eat as well as their own family member.
Observation on 9/17/19 at 12:19 P.M., showed residents from the unit in the dining room for the noon meal with two CNAs. The meal experience went as follows:
- Resident #26 threw a glass of ice water on Resident #145's face. Both staff left the dining room and assisted Resident #145 to his/her room to change clothes;
- With the dining room unattended, an unidentified resident reached into Resident #5's plate and grabbed food with his/her fingers and ate it;
- Resident #3 took a plate of food from Resident #30 and pulled it in front of his/her plate. He/she also took a red drinking glass from Resident #143 and started drinking from the red glass. He/she sat the red glass within arms length of Resident #30 who drank from the red glass;
- Staff re-entered the room, delivered a resident's tray and pushed Resident #30's plate back in front of him/her, then both staff left the dining room to assist a resident in room [ROOM NUMBER];
- With the dining room unattended, Resident #3 again moved Resident #30's plate away from him/her and continued eating his/her meal;
- Both Resident #3 and Resident # 30 continued to drink from the same red cup;
- Residents #1, #30 and #34 were not eating and no staff assisted the residents;
- Staff again re-entered the dining room, one staff started assisting Resident #27, the other staff passed desserts;
- Resident #3 picked up Resident #30's bowl of dessert and ate it;
- Both staff left the dining room to assist Resident #143 to his/her room, there were 11 residents remaining in the dining room some of which were eating.
During an interview on 9/17/19 at 12:59 P.M., CNA C said the red glass that both Resident #3 and #30 drank from actually did not even belong to Resident #143, it was Resident #11's cup from the activity prior to lunch.
During an interview on 9/17/19 at 1:09 P.M., CNA D said there were at least five, maybe six residents on the unit dining room that staff had to assist and a couple more that needed encouragement.
Observation on 9/18/19 at 12:29 P.M., showed 22 resident seated in the unit dining room. All residents had a plate in front of them except Resident #3. Staff did not notice the resident had not received a plate. The resident's plates had a lettuce salad on half the plate and the stuffed pepper casserole entree on the other half of the plate. Resident #11 ate his/her entree and then placed his/her plate in front of Resident #3 who began to eat the salad from Resident #11's plate. CNA D asked Resident #11 if he/she gave his/her plate to Resident #3, Resident #11 said he/she gave the resident his/her plate because the other resident did not get anything to eat. CNA D said he/she had not realized Resident #3 did not have a plate and went to the kitchen to get one. He/she returned to the dining room with a plate that contained an entree only, he/she sat the plate in front of the resident and left Resident #11's plate of salad for Resident #3 to eat.
During an interview on on 9/19/19 at at 2:20 P.M., CNA D said:
- Today the CNAs were allowed to bring in fewer residents at a time for the meal to be served;
- More staff including the Administrator, Director of Nurses, the new MDS Nurse and the Corporate Person had helped serve and assist feed the residents' breakfast and lunch today;
- The meals definitely went a lot smoother with less residents in the dining room at one time and more staff to assist everyone.
During an interview on 9/20/19 at 8:41 A.M., CNA C said:
- He/she worked as the transport staff for the facility, the restorative aide for the facility and as a CNA on the floor;
- He/she worked mostly on the floor on the unit;
- There was a lot of people in the dining room during meal times now;
- If one of the residents had a behavior, more residents acted out and was chaotic in the dining room;
- Staff sat residents who normally grabbed at other resident's food beside the residents who wouldn't allow anyone to take food off their plates;
- It was difficult to be able to monitor all the residents in the dining room, it was crowded and staff needed eyes in the back of their heads.
During an interview on 9/20/19 at 11:07 A.M., the Director of Nurses (DON) said:
- Staff needed to be able to monitor all residents in the dining room;
- Yesterday and today, the dining services on the dementia unit had gone much better with more staff to assist and fewer residents at a time in the dining room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure a bedtime snack was offered to every resident. Interviews with the Resident Council and dietary staff, showed staff placed a snack tub...
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Based on observation and interview, the facility failed to ensure a bedtime snack was offered to every resident. Interviews with the Resident Council and dietary staff, showed staff placed a snack tub in dining rooms, but did not go room-to-room to ensure that every resident, including dependent residents, were offered a bedtime snack. The facility census was 46.
1. During the Resident Council group meeting on 9/18/19 at 10:03 A.M., the four residents in attendance said:
-Residents are not offered snacks room to room each evening.
-There is a snack box located in the main dining room where residents can obtain snacks for themselves.
-Residents were concerned that dependent residents were not able to get snacks, or who would assist them in eating a snack.
-The residents felt bad that they could obtain snacks, but dependent residents could not.
2. Observation on 9/18/19 at 11:25 A.M., showed a plastic tub of assorted snack cakes, crackers and cookies stored on a counter across from the steam table in the kitchen. When asked about snacks, Dietary [NAME] A (DC A) said assorted snacks were placed in the tub and then put in the dining room between 7:00 and 8:00 P.M., so residents could get what they wanted. He/she said some residents come to the kitchen door before the tub was out and asked for a snack, so are given one then.
3. During an interview on 9/20/19 at 2:10 P.M., the Dietary Manager (DM) said snacks are available to residents throughout the day; that a snack tub is maintained with Fudge Rounds, cookies and crackers, as well as fruit. She said a tub is taken to the Alzheimer's Unit for evening snacks although snacks are available there during the day, too, and a tub is put in the dining room after supper for residents to take. She did not know if staff took snacks room-to-room and offered to all residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff used appropriate hand hygiene technique t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff used appropriate hand hygiene technique to prevent the spread of infection. This affected three out of 14 sampled residents (Residents #6, #7 and #143). The facility census was 46.
1. Review of the facility's August 2015 policy related to hand hygiene showed:
-This facility considers hand hygiene the primary means to prevent the spread of infections.
-Wash hands with soap and water when hands are visibly soiled, and after contact with a resident with infectious diarrhea.
-Use an alcohol-based hand rub containing at least 62% alcohol, or soap and water, before and after direct contact with residents, before and after handling invasive devices such as catheters, before moving from a contaminated body site to a clean body site during care, after contact with a resident's skin, after contact with blood or bodily fluids, after handling used dressings, after removing gloves, and before and after entering isolation precaution settings.
-The use of gloves does not replace hand washing/hand hygiene.
2. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/19, showed:
-Required extensive assistance for all care;
-Incontinent of bowel and bladder.
Review of the resident's care plan, last updated on 8/22/19, showed:
-Always incontinent of bowel and bladder;
-Assist with perineal cleansing as needed.
Observation on 9/17/19 at 6:43 A.M. showed Licensed Practical Nurse (LPN) A and Certified Nurse Aide (CNA) A provided care for the resident in the following manner as the resident lay in bed:
-CNA A handed LPN A moist wipes and LPN A cleansed the front genital areas.
-Staff turned the resident to his/her side LPN A cleanse a small amount of fecal material from the resident's backside.
-With the same soiled gloves on, LPN A then helped put pants on the resident, picked up a lift sling and helped CNA A position it under the resident, opened a bedside drawer and obtained a pair of socks, put the socks on the resident, then removed his/her gloves and washed his/her hands.
-Both staff transferred the resident from the bed to a wheelchair.
-CNA A washed the resident's face, removed his/her gloves, but did not wash or sanitize his/her hands, then took the resident out of the room.
-LPN A sanitized his/her hands and remained to provide care for the resident's roommate.
During an interview on 9/20/19 at 10:52 A.M., LPN A said staff should remove their gloves and wash or sanitize their hands after they provide incontinent care, before they touch anything else.
3. Review of Resident #7's admission MDS, dated [DATE], showed:
-Totally dependent for personal hygiene and toileting;
-Incontinent of bowel and bladder.
Review of the resident's care plan, last updated on 8/20/19, showed:
-Incontinent of bowel and bladder/
-Provided perineal cleansing as needed.
Observation on 9/19/19 at 9:11 A.M. showed LPN A and CNA A provided care for the resident in the following manner as the resident lay in bed:
-Both staff washed their hands and put on gloves.
-LPN A handed CNA A moist wipes as he/she cleansed the resident's front and back genital areas.
-CNA A removed his/her gloves, washed hands and put on new gloves, then LPN A squeezed barrier cream onto CNA A's glove and CNA A applied the barrier cream to the resident's buttocks.
-CNA A removed his/her gloves, did not wash or sanitize his/her hands, and left the room to obtain a clean sheet.
-CNA A returned with the sheet but did not wash or sanitize his/her hands after he/she entered the resident's room.
-Both staff removed the soiled sheet and placed the clean sheet on the bed.
-LPN A removed his/her gloves and washed his/her hands.
-CNA A raised the resident's head of bed, then washed his/her hands and left the room.
During an interview on 9/19/19 at 2:10 P.M., CNA A said:
-Staff should sanitize or wash their hands when they enter a resident's room, before they leave the room, after they assist with personal hygiene.
-Staff should remove their gloves and wash or sanitize their hands after they provide incontinent care.
4. During an interview on 9/20/19 at 11:07 A.M., the Director of Nurses (DON) said staff should remove their gloves and wash or sanitize their hands after they provide incontinent care, before they touch anything else. They should wash or sanitize their hands before they leave the resident's room.
5. Review of the facility's undated infection control policy for MRSA-Methicillin Resistant Staphylococcus Aureus, (bacteria) showed:
- Handle, transport and process used linen soiled with blood, fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environment.
Review of Resident #143's MDS, dated [DATE], showed:
- Difficulty making daily decisions;
- Required extensive assist of staff with activities of daily living;
- Frequently incontinent of urine and fecal matter;
- Diagnosis of wound infection.
Review of the resident's care plan dated 9/13/19, showed:
- Potential for infection related to wound. Currently on antibiotics for MRSA to the stage IV wound on coccyx;
- Monitor for any changes in mental status and report changes to physician;
- Assess vital signs as ordered:
- Report any abnormal labs to the physician in a timely manner;
- Administer medication as ordered.
Observation on 9/19/19 at 9:15 A.M., showed the resident lay in bed on an incontinent pad stained with a large brown ring of loose watery fecal material. Certified Nurse Aide (CNA) B and CNA D provided incontinent care, The resident had a dressing over his/her coccyx area which had come loose. Staff asked Licensed Practical Nurse (LPN) B to come in and replace the dressing. After the dressing change and incontinent care was completed. Staff bagged up the resident's trash and soiled linens in clear plastic bags they placed in the soiled utility room with other resident's linens.
During an interview on 9/19/19 at 2:20 P.M., CNA D said:
- Resident #143 had MRSA in his/her wound;
- He/she knew if the bandage was not covering the wound staff should get the nurse and not touch it;
- He/she needed to use good handwashing:
- Probably the linen and trash should be bagged differently, but there weren't any red barrels in the room.
During an interview on 9/20/19 at 11:07 A.M., the DON said:
- The facility did not put up a notice on the resident's door to see the nurse before entering due to it being a violation of HIPPA (legislative provision to safeguard healthcare information);
- The charge nurses were responsible to inform staff of any infection the residents had;
- There should have been red barrels and red trash bags in the resident's room for proper handling of trash and linens.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0920
(Tag F0920)
Could have caused harm · This affected multiple residents
Based on observation and interview, facility staff failed to provide a dining room large enough to accommodate the residents in the Alzheimer's Unit. There were 22 residents eating in the Alzheimer Un...
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Based on observation and interview, facility staff failed to provide a dining room large enough to accommodate the residents in the Alzheimer's Unit. There were 22 residents eating in the Alzheimer Unit dining room. The facility census was 46.
1. Observation on 9/17/19 at 8:18 A.M., showed residents in the dining room for breakfast. Two tables were pushed together, nine residents sat at that table. One square table had five residents pushed up to that table and one round table had five residents and a family member seated at the small round table. Two staff members assisted residents into the dining room. At times staff needed to move a resident from their plate so they could assist another resident to their dining spot. The two staff also delivered trays of food to residents and assisted residents as they could.
Observation on 9/17/19 at 12:19 P.M., showed residents on the unit in the dining room for the noon meal. Five residents were seated around the round table and five residents around the square table. The square table also had a staff member seated at the table, the round table had a family member also seated at the table. An unidentified resident sat down beside Resident #5's family member, moved his/her arm over a few inches and with his/her fingers took food off the other resident's plate and ate it. Also in the dining room was a three tiered cart that dietary staff placed resident's meals on and another three tiered cart that contained drinks and a tray of desserts.
Observation on 9/18/19 at 12:29 P.M., showed 22 resident seated in the Alzheimer's Unit dining room. Five residents sat at the round table and five residents sat at two square tables each. All residents had a plate in front of them except Resident #3. Staff did not notice the resident had not received a plate. Walking between the tables in the dining room was difficult to maneuver with residents seated around the tables and the two three-tiered carts in the small dining area.
During an interview on 9/20/19 at 8:41 A.M., CNA C said:
- He/she worked as the transport staff for the facility, the restorative aide for the facility and as a CNA on the floor;
- He/she worked mostly on the floor on the unit;
- There was a lot of people in the dining room during meal times now;
- If one of the residents had a behavior, more residents acted out and was chaotic in the dining room;
- Staff sat residents who normally grabbed at other resident's food beside the residents who wouldn't allow anyone to take food off their plates;
- It was difficult to be able to monitor all the residents in the dining room, it was crowded and staff needed eyes in the back of their heads.
During an interview on 9/20/19 at 11:07 A.M., the Director of Nurses said:
- On the unit it was difficult to know which residents needed staff assistance, today the resident may eat fine, tomorrow they might would not eat at all and need assistance;
- Staff needed to be able to monitor all residents in the dining room;
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 safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 3 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 63 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • $13,000 in fines. Above average for Missouri. Some compliance problems on record.
- • 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 Lawson Manor & Rehab's CMS Rating?
CMS assigns LAWSON MANOR & REHAB 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 Lawson Manor & Rehab Staffed?
CMS rates LAWSON MANOR & REHAB's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 75%, which is 29 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Lawson Manor & Rehab?
State health inspectors documented 63 deficiencies at LAWSON MANOR & REHAB during 2019 to 2025. These included: 3 that caused actual resident harm, 57 with potential for harm, and 3 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Lawson Manor & Rehab?
LAWSON MANOR & REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CIRCLE B ENTERPRISES, a chain that manages multiple nursing homes. With 60 certified beds and approximately 44 residents (about 73% occupancy), it is a smaller facility located in LAWSON, Missouri.
How Does Lawson Manor & Rehab Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, LAWSON MANOR & REHAB's overall rating (1 stars) is below the state average of 2.5, staff turnover (75%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Lawson Manor & Rehab?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Lawson Manor & Rehab Safe?
Based on CMS inspection data, LAWSON MANOR & REHAB has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). 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 Lawson Manor & Rehab Stick Around?
Staff turnover at LAWSON MANOR & REHAB is high. At 75%, the facility is 29 percentage points above the Missouri average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Lawson Manor & Rehab Ever Fined?
LAWSON MANOR & REHAB has been fined $13,000 across 1 penalty action. This is below the Missouri average of $33,209. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Lawson Manor & Rehab on Any Federal Watch List?
LAWSON MANOR & REHAB is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.