AVALON VIEW HEALTH AND WELLNESS
For profit - Corporation
140 Beds
VERTICAL HEALTH SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
6/100
#335 of 479 in MO
Photo by Avalon View Health and Wellness
Photo by Avalon View Health and Wellness
Photo by Ashlee Siard
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Avalon View Health and Wellness has a Trust Grade of F, indicating a poor rating with significant concerns about care quality. It ranks #335 out of 479 facilities in Missouri, placing it in the bottom half, and #7 out of 9 in Clay County, meaning there are only two facilities in the area with worse ratings. The facility is showing signs of improvement, having reduced issues from 23 in 2024 to just 2 in 2025. However, staffing is a concern, with a low RN coverage rating, which is below that of 76% of Missouri facilities, and a staffing turnover rate of 62%, near the state average. Additionally, the facility has faced critical incidents, such as failing to provide adequate assistance devices for a bariatric resident during emergencies, which could put residents at risk. There have also been serious deficiencies, including a failure to prevent a resident with a history of aggressive behaviors from harming others, and neglecting proper wound care for residents that led to hospitalization. While there are some strengths in their quality measures, families should weigh these serious weaknesses in care and safety before considering this facility.
- Trust Score
- F
- In Missouri
- #335/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $14,267 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 101 deficiencies on record. Higher than average. Multiple issues found across inspections.
6/100
Bottom 31%
Review needed
23 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 23 issues
2025: 2 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 62%
15pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $14,267
Below median ($33,413)
Minor penalties assessed
Chain: VERTICAL HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (62%)
14 points above Missouri average of 48%
The Ugly 101 deficiencies on record
1 life-threatening 3 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure the environment for one (Resident #1) of five sampled residents remained free of accident hazards and additionally failed to follow t...
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Based on interview and record review the facility failed to ensure the environment for one (Resident #1) of five sampled residents remained free of accident hazards and additionally failed to follow their own transportation policy when the resident was injured during transportation in facility vehicle as a result of not being properly restrained and supervised by the facility designated driver. The facility census was 111.Review of the facility's Transportation Driving Safety Policy, dated reviewed on 08/10/24, showed:- It is the drivers responsibility to operate the vehicle in a safe manner and to drive defensively to prevent injuries and property damage;- Drivers of company vans, buses, or vehicles carrying patients should have at least three years of driving experience and will be required to complete initial and annual training per manufacturers guidelines to include how to properly restrain a wheelchair and use of safety mechanisms for residents in wheelchairs per manufacturers guidelines and van safety;- The driver shall ensure each passenger is properly restrained to include wheelchair(s) properly fastened and shoulder strap in place and/or passenger seat belts are properly latched;- All drivers and passengers operating or riding in a company vehicle must wear seat belts.On 09/19/2025, the Administrator was notified of the past noncompliance which occurred on 08/25/25. On 08/25/25, facility administration conducted an investigation immediately began and implemented corrective actions to include:- Resident #1 was assessed, primary physician notified, and family notified;- Employee #1 and Director of Maintenance were suspended pending the investigation;- Administrator/designee re-educated the Director of Maintenance;- All staff who are responsible for transportation were re-educated using facility competency that follows manufacturer's guidelines for transport safety restraints and have completed return demonstrations on use prior to future transports;- Facility has a standard competency to ensure proper demonstration is performed by all staff responsible for resident transport prior to transporting residents (which had been provided and reviewed); - The senior maintenance director inspected the facility van including safety restraints to ensure all components are in good working order prior to resident transport and the inspections will be audited by the Administrator for compliance; - Facility will validate driving record for staff who are responsible for transporting residents and the validations will be monitored by the Administrator ; - Future employees that will be transporting residents in the facility van will be educated on manufacturer guidelines and perform competency demonstrations prior to transporting residents. Monthly audits will be performed by maintenance to ensure all components are in proper working condition. -The non-compliance was corrected on 09/02/25.1.Review of Resident#1s Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/23/25, showed:- Cognitive skills intact;- Dependent on staff for all cares;- Diagnoses included: Central cord syndrome at unspecified level of cervical spinal cord, contractures, and neurogenic bladder. Review of Resident #1's care plan, revised 8/28/25, showed:- The resident was hit by a bus last year causing major injuries. Trauma informed care assessment will be administered upon quarterly, annually, and as needed - Trauma informed care assessment was re-administered on 8/26/25;- The resident is non-weight bearing;- The resident is dependent on staff for bathing, toileting, and transfers;- The resident has limited physical mobility related to central cord syndrome (a type of incomplete spinal cord injury that affects the upper motor neurons in the center of the spinal cord. This damage leads to weakness, sensory loss, and other neurological problems primarily in the arms and hands). Review of nursing progress notes showed:- On 8/25/25 at 6:17 P.M. Licensed Practical Nurse (LPN) A documented the resident was in facility van being transported from appointment. When the driver stopped at red light, the resident slid out of wheelchair to floor and landed on his/her left side. The resident hit the left side of his/her face/forehead on the back of the driver's seat. No redness/swell to face/forehead. The resident denies pain;- On 8/25/25 at 6:18 P.M. the Director of Nursing (DON) documented the physician was notified and new orders obtained to monitor the resident for decreased range of motion (ROM) in extremities, obtained vital signs (VS) every shift, and to monitor for worsening pain from baseline for 72 hours. The resident currently doesn't have any new onset of pain. ROM is at baseline;- On 8/28/25 late entry-with effective date 8/26/25 at 10:15 A.M. Interdisciplinary Team (IDT) Progress note: IDT team met and discussed residents fall. Resident is alert and oriented and able to make his/her needs known. Resident was in wheelchair at the time of fall and slid out of wheelchair. Resident has bilateral lower extremity contractures at knee level at baseline. The resident denies any worsening or new onset of pain. Nonslip mat applied to wheelchair to help aid in traction and prevent resident from slipping out of wheelchair. All parties notified.During an interview on 9/3/25 at 10:40 A.M., the Resident said:- He/She didn't have a seat belt on the wheelchair while in the facility van;- He/She had used transportation van before and this had never happened. This was the first time with this driver from the facility;- The driver locked his/her wheelchair in place but did not put the seatbelt across him/her;- The driver was on the highway and went to get into the outer lane, the driver sped up and car in front hit the brakes, the driver then hit the brakes, and it threw him/her forward and smacked into the cushion on the back of the driver seat;- He/She rode on the floor of the van all the way back to the facility;- He/She was not hurt but the idea of no safety precautions taken worried him/her; - The facility notified his/her family and representatives;- The facility told him/her they would make sure they used a seat belt for all wheelchairs when in the van from now on.During an interview on 9/3/25 at 12:00 P.M., the DON said: - Nothing was missing or not working in the transportation van;- The facility Maintenance Director trains staff on procedure for securing residents in the van;- The transportation driver is new at transportation but was a certified nursing assistant (CNA) and had worked at the facility for awhile. During an interview on 9/3/25 at 12:16 P.M., the Transportation driver said:- He/She had just recently started transportation; - He/She was pulling up to the last stop light before arriving at the facility, came to a stop and the resident slid out of his/her chair falling forward into the back of the driver seat; - The Resident was locked into the van with the wheelchair hooks in place. The lap belt was not on, He/she had simply forgot to put it on; - He/She stopped the vehicle to check the resident, believed the resident was okay, and continued driving to the facility; - After arriving at the facility, he/she got out and knocked on the front door and staff came out to help and got the resident up off the floor of the van;- Seat belts and straps are to always be applied;- He/She had a review of safety best use with the Maintenance Director after the incident and went over the transportation checklist; - The Administrator had him/her demonstrate the loading and securing resident procedure on 9/2/25. During an interview on 9/3/25 at 1:20 P.M., the Administrator said: - The transportation driver should always apply proper restraints and residents should be safely secured in their wheelchairs during transport; - The Regional Maintenance signed off on the facility Transportation driver's training, with him/her, after the incident;- He/She had stopped all transportation until he/she verified through return demonstration the transportation driver could use safety belts and transport residents safety, this was completed on 9/2/25. During an interview on 9/3/25 at 1:25 P.M. the Maintenance Director said: - He/She did instruct the Transportation driver on how to apply the seat belt strap, all four ratchet straps for the wheelchairs, and the shoulder strap which connects with the seat belt if needed, after the incident; - He/She showed the Transportation driver how to lock all the wheels on the wheelchairs after the incident; - He/She showed and demonstrated all the procedures to the transportation driver and had them show and demonstrate the procedures back to him/her after the incident. During an interview on 09/16/2025 at 2:25 P.M. the Resident said: - He/She did feel that something was missed by not having the seatbelt applied and felt it was negligent;- He/She felt some pain around his/her eye after the incident but there wasn't any bruising or cuts;- He/She felt the driver did okay after he/she had fallen by looking back to see if he/she was okay and since they were close to the facility, went back to the building;- The facility had used seatbelts before, just didn't this time. During an follow-up interview on 09/18/2025 at 1:47 P.M., the Administrator said:- The process for new staff drivers going forward would be that everybody's driving record would be checked and the staff member would complete the training with the check off list;- There is a daily check off list with the van now;- No staff member would transport residents in the facility van without completing the competency and performing a return demonstration so that he/she feels confident enough in their ability;- He/she, the Regional Maintenance person, or the corporate vice president are the ones that will ensure the competencies are completed and the process is audited properly;- A resident should be safely secured in the wheelchair during transport;- She had been offsite before the Transportation Driver's first transport and the driver was supposed to only set up appointments, not drive the van at that time;- The transportation driver has since been properly instructed how to use and apply seat belts to residents, how to apply and lock the four-point ratchet straps, and how to lock wheelchair wheels and has done an excellent job;- She had Regional Maintenance come in the day after the incident to do competencies with the driver; - She had completed driver check offs with return demonstration on 09/02/25 with the Transportation Driver; - The Administrator or designee are responsible to audit the maintenance check off sheets and staff record reviews;- We hadn't used facility transport for a while prior to this and had used other medical transport.During a follow-up interview on 09/18/2025 at 1:55 P.M., the Transportation Driver said:- Before she drove further, after the resident slid forward, she turned to ask and ensure the resident was okay, checked the resident's positioning, then proceeded to the facility since it was in such close proximity;- Prior to the incident, she had been with the Business Office Manager (BOM) at the front desk and the BOM offered to show her the buckles in front and back to stabilize wheelchair and lock into place, and that was it;- Since the incident, she had gone over the checklist with maintenance and had the competency completed and teach back performed;- Maintenance and the Administrator have both trained her and she signed off on the competency sheets;- She hadn't been aware of the seatbelt, the BOM hadn't shown her that;- The resident didn't say anything when he/she fell but did respond to questions saying he/she was okay and that when he/she had slid forward hitting the front right part of his/her head on the back of the driver's chair. There was no obvious injury that she could see;- When he/she got back to the facility, the DON went out to the van and assessed the resident before anyone moved him/her, then two male staff members from therapy came out, positioned the resident, scooped him/her up and placed into a wheelchair outside the van. The resident was then taken inside for further assessment.During a follow-up interview on 09/18/25 at 2:04 P.M., the DON said:- The seatbelts should be used to secure residents for transport;- If a resident were to fall during transport and if further away from the facility or injured, she would expect the driver to stop and call 911 for assistance;During a follow-up interview on 09/18/2025 at 2:09 P.M., the Maintenance Director said:- Going forward, before any new driver would start, he would properly train them to strap, load residents using the ramp, lock wheels, straps, and locks, then ensure seat belt is applied;- Every resident should be secured in a seat belt properly;- The transportation driver is the only driver we have and has now been trained properly.Intake 2604452
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when Resident #2 hit Resident #1 in the back. Resident #1 was noted to have redness to his/her back. The facility census was 108.
On 4/2/25 the Administrator was notified of the past noncompliance which began on 3/24/25. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 3/24/25.
Review of the facility's Abuse, Neglect and Exploitation policy, dated 8/22/2022, showed:
-It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property;
-Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish;
-Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment;
-Identification of Abuse, Neglect and Exploitation: Possible indicators of abuse include, but are not limited to:
1. Resident, staff or family report of abuse.
2. Physical marks such as bruises, patterned appearances such as a hand print, belt or [NAME] mark on a resident's body.
3. Physical injury of a resident, of unknown source.
6. Physical abuse of a resident observed.
1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 3/6/25, showed:
-The resident has the diagnoses of dementia with agitation (a group of thinking and social symptoms that interferes with daily functioning), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), , low back pain, mood disorder (a mental health condition characterized by persistent and pervasive change in a person's emotional state) and dysphagia (difficulty swallowing);
-He/She has adequate hearing, clear speech, understands other and is able to make self understood;
-He/She scored 3 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates severely impaired cognitive abilities;
-He/She has displayed no behaviors.
Review of Resident #1's comprehensive care plan, dated 3/24/25, showed:
The resident has a behavior issue related to wandering and rummaging in peer's rooms. He/She had a resident-to-resident altercation on 3/24/25. He/She requires staff supervision during meals. Staff to intervene as necessary to protect the rights and safety of others. Approach and speak to the resident in a calm manner. Divert the resident's attention. Remove the resident and take him/her to an alternate location as needed. Assess the resident for pain, hunger, thirst, care needs.
2. Review of Resident #2's quarterly MDS, dated [DATE], showed:
-The resident has the diagnoses of aphasia (a language disorder that affects a person's ability to communicate), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) , seizures (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), mild cognitive impairment (the in-between stage between typical thinking skills and dementia), dementia;
-The resident has adequate hearing, clear speech, usually understands others and usually makes self understood;
-He/She scored zero on the BIMS, indicating severely impaired cognitive abilities;
-He/She displays verbal behaviors.
Review of Resident #2's comprehensive care plan, dated 3/31/25, showed:
-The resident has potential to be physically aggressive (hitting, breaking things) related to anger. He/She had a resident-to-resident altercation on 3/24/25. Staff will administer medications to the resident as ordered. Analyze times of day, placed, circumstances, triggers and what de-escalates behavior. Staff will provide physical and verbal cues to alleviate anxiety. Staff will assess and anticipate the resident's needs. When the resident becomes agitated, staff will intervene before agitation escalates, guide them away from the source of distress, engage calmly in conversation.
Review of the facility investigation, dated 3/24/25, showed:
-On 3/24/25 at 7:50 A.M., Certified Medication Technician (CMT) A notified the charge nurse, Licensed Practical Nurse (LPN) A of a physical altercation between Resident #1 and Resident #1. CMT A stated that Resident #2 was seated at a table in the dining area and Resident #1 walked by. Resident #2 yelled at Resident #1 to go away and then reached out and hit Resident #1 on the back. CMT A intervened, separated the residents and notified the charge nurse. Both residents were assessed, and Resident #1 was noted to have redness to his/her back;
-During interviews conducted shortly after the altercation, neither resident could recall the incident. Both residents responded that they feel safe in the facility.
- Summary of actions taken include, residents assessed and monitored, physician and responsible parties were notified, environmental changes were implemented to reduce future incidents including: Increase staff support at meal times, staff to observe resident participation in table clearing after meal service, laminated Spanish reminder placement for Resident #1 before cleaning.
- Trauma Informed Care interventions were completed for both residents.
- Evaluation completed by mental health professional services, medications reviewed and care plans updated accordingly.
During an interview on 4/2/25 at 145 P.M. CMT A said:
-CMT A was in the dining room, helping residents get ready for breakfast and passing medication. Resident #2 was sitting at the dinning table, waiting for breakfast. Resident #1 walked by Resident #2's table. Resident #2 yelled at Resident #1 to go away and then reached out and hit Resident #1 on the back;
-CMT A immediately separated the two residents and notified the charge nurse.
During an interview on 4/2/25 at 2:40 P.M., LPN A said:
-At approximately 7:50 A.M., CMT A told LPN A that there was an altercation between Residents #1 and #2. Resident #2 yelled at and hit Resident #1 in the back when he/she walked by Resident #2's table. CMT A separated the residents and notified the charge nurse;
-LPN A assessed both residents. Resident #2 had no injuries. There was redness noted to Resident #1's back. LPN A notified the Director of Nursing (DON), physician, and responsible parties.
During an interview on 4/2/25 at 2:12 P.M., the Administrator said:
-Resident #1 has a history of working as a housekeeper and server. He/She frequently walks around the memory care unit, attempting to tidy up rooms, clear tables and other housekeeping tasks. He/She often needs redirection at mealtime to avoid cleaning tables before other residents are done;
-Resident #2 has a history of being a registered nurse and a Director of Nursing at a long-term care facility. He/She frequently reverts to his/her previous occupation, attempting to oversee and direct staff and other residents. He/She enjoys assisting with small tasks and prefers everything to be well organized;
-Staff education involving de-escalation, abuse and neglect, and intervention strategies was started and completed on 3/24/25;
-Meal schedules on the memory care unit were re-evaluated to provide increased staffing support during meal times;
-Staff are supporting and assisting Resident #1 in clearing tables after meals;
-Laminated placemats have been placed on the tables, with a note in Spanish, to cue Resident #1 in asking for staff assistance before clearing tables.
MO251626
Sept 2024
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect, when staff ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect, when staff failed to cover up a resident (Resident #71) who was walking down the hallway in a white pull-up brief, without pants, and failed to assist a resident into his/her personal clothes when requested by the resident (Resident # 74). The facility also failed to provide a resident with clean bed pads and sheets so he/she could return to bed after an incontinent episode (Resident #49). This affected two of 21 sampled residents. The facility census was 104.
The facility did not provide a policy on resident dignity.
Review of nursing home Resident's Rights, showed:
-Residents had a right to be treated with consideration, respect, dignity, and recognizing each resident's individuality.
-Equal access to quality of care;
-Quality of life is maintained or improved.
1. Review of Resident #71's significant change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/29/24, showed:
-He/She was cognitively intact;
-He/She required substantial/maximal assistance with his/her personal hygiene and lower body dressing;
-He/She required supervision or touching assistance with transfers from chair to bed, mobility from sitting to lying;
-He/She was dependent on a wheelchair;
-He/She did not attempt walking 10 feet due to medical condition or safety concerns;
-Diagnoses included: Arthritis, schizophrenia (a mental illness that affects a person's thoughts, feelings, and behaviors), anxiety disorder (a condition that causes excessive worry and fear that can affect a person's daily life), bipolar disease (a mental illness that causes extreme mood swings, or shifts in energy, activity levels, and concentration), depression (a mental health condition that can cause a persistent low mood or loss of interest in activities), need for assistance with personal care, generalized muscle weakness, difficulty walking, tendency to fall, and bone infection of left ankle and foot.
Review of the resident's care plan, revised 8/2/24, showed:
-Receive adequate and appropriate care;
-Resident has a right to privacy and confidentiality;
-Resident had an activities of daily living self-care performance deficit.
-Resident was able to walk independent 10 feet, 50 feet with 2 turns and 150 feet;
-Resident required staff assistance to extent needed to accomplish task.
-Resident was an elopement risk/wanderer.
Observation on 9/18/24 at 9:59 A.M. showed the resident walking up Maple hall wearing no pants and only a white pull up brief. He/She walked pass the nurses station, passed Registered Nurse (RN) A, and continued down the hallway. He/She was met by a therapy staff member who offered to take the resident to the therapy room. The resident was then walked past the [NAME] nurses station, rooms B20, B19, B9, B10, B18, and into therapy with no pants on. Multiple residents, staff, and family members observed witnessing the resident.
2. Review of Resident #49's Quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had clear speech, and was able to make self-understood and understand others;
-He/She felt down, depressed or hopeless half or more days;
-He/She had no behavioral symptoms or rejection of care;
-He/She had impairment on one side of upper and lower extremities;
-He/She was dependent on walker and wheelchair;
-He/She required substantial/maximal assistance with bathing
-He/She was frequently incontinent;
-Diagnoses included: Stroke (condition causing damage to the brain from an interruption of its blood supply), hemiplegia (condition causing weakness on one side of the body), heart failure, high blood pressure, diabetes (too much sugar in the blood), depression, post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, lack of coordination, pain in left shoulder, need for assistance with personal care, osteoarthritis of the right shoulder (a chronic joint disease that causes the cartilage in one or more joints to break down over time).
Review of resident's care plan, revised 7/30/24, showed:
-He/She had an ADL self-care performance deficit due to hemiplegia;
-He/She required extensive assistance with one person assist for shower twice weekly and as necessary;
-He/She required assistance washing under his/her arm, abdominal folds, and lower body;
-He/She had a rash under breast and pannus due to moisture;
-Preventive skin care as ordered, keep area under breast and pannus clean and dry.
During an interview on 9/16/24 at 6:32 P.M., the resident said:
-He/She felt staff were degrading at times and treated him/her like he/she was a kid and could not think for him/herself;
-He/She had staff tell him/her that he/she needed to go to the bathroom;
-Staff wake him/her up at 4:00 A.M. to go to the bathroom;
-Staff will wake him/her up to go to the bathroom and then not have clean sheets to put back on his/her bed;
-He/She is forced to sit up and not able to go back to sleep;
-He/She was a night owl and it is difficult for him/her not to be able to go back to bed after being awakened.
During an interview on 9/16/24 at 12:11 P.M., Certified Nurse Aide (CNA) A said:
-The laundry staff do not restock linens;
-He/She had to go to laundry room to locate bed pads and sheets;
-It took him/her away from patient care when he/she had to go down and try and locate clean sheets and bed pads.
During an interview on 9/17/24 at 5:18 A.M., Licensed Practical Nurse (LPN) A said:
-There had been issues with bed pads and sheets;
-The washing machine had broke down;
-The facility got disposable pads to put on beds.
During an interview on 9/17/24 at 5:48 A.M., CNA B said:
-There had been issues with supplies of linens and bed pads;
-They had ran out of linens and bed pads in the past few months several times.
3. Review of Resident #74's admission assessment, completed by facility staff, dated 9/10/24, showed:
-He/She was cognitively intact;
-Always incontinent of bowel and bladder;
-Diagnoses included: Non-traumatic brain dysfunction( brain damage or acquired brain injury ) shortness of breath, urinary tract infection, asthma, heart disease, depression, osteoarthritis, and malnutrition.
Review of the resident's undated care plan, showed:
-Resident's autonomy and dignity will be honored in the personal choices they make;
-Resident had an ADL (activities of daily living self-care) performance deficit;
-Resident was at risk for falls.
During an observation and interview on 09/16/24 9:59 A.M., the resident stated he/she liked to be dressed by 8:30 A.M. and did not understand why he/she was not dressed yet. The resident was physically upset about not being dressed by the staff. The resident was observed in a hospital gown and had been waiting to get dressed since 8:30 A.M. Observation showed the staff having a discussion outside the resident's room regarding the resident not having any clean pants to put on.
During an interview on 9/17/24 at 5:59 A.M., the Administrator said residents deserved to be treated with dignity and respect.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, the facility staff failed to ensure residents had access to their personal funds after business hours and o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, the facility staff failed to ensure residents had access to their personal funds after business hours and on the weekends. This impacted three of 21 sampled residents (Resident #83, #28, and #5). The facility census was 104.
The facility did not provide a policy regarding access to resident funds.
1. Review of Resident #83's Significant change minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/26/24, showed:
-He/She had moderately impaired cognition;
-He/She had clear speech, was able to make self-understood and understand others;
-Diagnoses included depression, cancer of the colon, high blood pressure, and diabetes (too much sugar in the blood).
During an interview on 9/16/24 at 12:20 P.M., the resident said:
-He/She does not always have access to his/her money;
-The facility said that they had not gone to the bank, so they did not have money to give him/her.
2. Review of Resident #28's admission MDS, dated [DATE], showed:
-He/She had moderately impaired cognition;
-He/She had clear speech, and was able to make self-understood and understand others;
-He/She had diagnoses of chronic obstructive pulmonary disease (a condition making it difficult to breath), alcohol dependence, high blood pressure, and dementia (condition causing a decline in mental function such as thinking, remembering, and reasoning, that interferes with daily life).
During an interview on 9/16/24 at 7:30 P.M., the resident said:
-He/She did not have full access to his/her money.
3. Review of Resident #5's Quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had clear speech, and was able to make self-understood and understand others;
-He/She had diagnoses of anxiety (feeling of fear, dread, or uneasiness that can be a normal reaction to stress), wound infection, and high blood pressure.
During an interview on 9/16/24 at 1:14 P.M., Resident #5 said:
-He/She had asked for money, but had been denied money when the facility stated they had not gone to the bank.
During an interview on 9/19/24 at 3:35 P.M., the Business Office Manager (BOM), said:
-Receptionist A distributes resident funds;
-When residents want money they go up to the front desk and make a request with receptionist A;
-Residents come and request money daily;
-Resident cash turn around request time is one day;
-If it is a holiday the facility does not disburse any cash;
-He/She did not know if the weekend receptionist had access to cash;
-He/She had not had residents ask for cash on weekends;
-On Fridays residents usually take out extra money to get them through the weekend;
-Receptionist A and B have access to cash box;
-Total amount available in facility cash had been increased due to running out of cash on hand to meet resident requests;
-He/She could cut checks for petty cash;
-Facility administrator has to go and cash all facility petty cash checks and ensure facility had cash in house;
-He/She is in the building until 8:30 or 10:00 P.M. and has not had a resident request cash after Receptionist A left the building;
-He/She may need to educate residents on the availability of funds after Receptionist A leaves for the day.
During an interview on 9/19/24 at 3:47 P.M. Corporate Accounting said:
-The BOM made a request to have cash in facility increased;
-The max on hand in the facility was $500.00 which did not meet resident request needs;
-In July cash on hand was increased to $1500.00
During an interview on 9/23/24 at 3:33 P.M., Administrator said:
-Funds were available during banking hours;
-He/She was the only facility staff who was authorized to go to the bank to cash checks;
-There had been a delay in obtaining cash on hand for residents in the facility when he/she had been off work as there had been no staff designated to go obtain cash to replenish the petty cash on hand in the facility;
-Residents were able to get funds on same day of their request;
-There had been an instance prior to the increase in the in house funds amount that residents were denied access to personal funds as the facility did not have funds on hand.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure the code status matched in all places of the clinical record for one resident (Resident #35) out of 23 sampled resident...
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Based on observation, interview and record review, the facility failed to ensure the code status matched in all places of the clinical record for one resident (Resident #35) out of 23 sampled residents. The facility census was 104.
The facility's Advance Directive policy was not provided.
1. Review of Resident #35's admission Minimum Data Set (MDS) assessment, a federally mandated assessment instrument completed by facility staff, dated 7/17/24 showed:
Diagnoses included: mild cognitive impairment; Diabetes; Kidney Failure; High Blood Pressure; Gastroesophoageal reflux disease (GERD); and Obstructive uropathy (urinary blockage)
Review of resident's physician's orders, dated 7/16/2024, showed:
-Full code (Provide life saving measures) status.
Review of the resident's Outside the Hospital Do Not Resuscitate Order form (OHDNR) signed on 8/22/24 showed:
-Code status as a DNR (Do Not Resuscitate).
Review of resident's undated care plan showed:
-Resident was a full code status.
During an interview on 09/23/24 at 10:16 A.M, certified nurse aide (CNA) A said the resident's code status is in residents' chart and he/she had memorized who is a full code and who is not.
During an interview on 09/23/24 at 09:55 A.M., registered nurse (RN) A said Resident #35 was listed as a full code per the medical record. He/she noticed the discrepancy in the resident's chart during the interview and changed the code status to DNR.
During an interview on 09/23/24 at 04:20 P.M., the Director of Nursing (DON) and Administrator said:
-The protocol for handling an unresponsive resident includes triage, code blue, and determine the code status.
-The DON and Administrator expect staff to check the code book and the chart to find a resident's code status.
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 F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure confidentiality of records was maintained for two of 21 sampled residents (Resident #80 and #153) when durable power o...
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Based on observation, interview, and record review, the facility failed to ensure confidentiality of records was maintained for two of 21 sampled residents (Resident #80 and #153) when durable power of attorney document (DPOA) paperwork for Resident #80 was given to an unauthorized person by facility staff and when empty medication packaging was observed outside the facility on the ground with Resident #153's personal information on the label. The facility census was 104.
Review of the facility's Health Insurance Portability and Accountability Act (HIPAA) Policy dated, 9/1/21, showed in part:
-It is the facility's policy to implement reasonable an appropriate measures to protect and maintain the confidentiality, integrity and availability of the resident's identifiable information or records;
-Security measures will be implemented to manage risks and vulnerabilities.
Review of the facility's Resident Rights Policy revised, 9/1/22 did not address the residents right to privacy and confidentiality.
Review of the Missouri Resident [NAME] of Rights, provided through the state long term are ombudsman (a person who represents the interests of residents) program included residents have the right to privacy, to be treated with consideration, respect, and dignity, recognizing each resident's individuality.
1. Review of Resident #80's care plan revised, 6/13/24,showed:
-The resident has the right to privacy and confidentiality.
Review of the resident's medical record showed:
-A DPOA document, (a legal document that names a person/agent who may continue to act on your behalf even after you have an incapacitating illness or accident);
-The resident's family member A was listed as the agent.
Review of the resident's nurse's note dated 5/14/24 showed:
-Social services note: Family member A is the only person to have access to health information and other protected information.
During an interview on 9/17/24, at 1:22 P.M., family member A said:
- An unauthorized family member came to the facility and told the administrator he/she was family member A;
-The administrator gave a copy of the resident's DPOA to the unauthorized family member;
-He/she expected the facility to verify the identify of the person asking for the resident's protected personal information;
-He/she expects the facility to protect the resident's right to privacy.
During an interview on 09/17/24, at 11:10 A.M., the administrator said:
-An unauthorized family member came to the facility and said he/she was the resident's DPOA;
-He/she gave the unauthorized family member a copy of the DPOA paper work;
-He/she realized after a phone call from the DPOA that he/she had given the DPOA paper work to an unauthorized person;
-He/she should have asked for photo identification;
-He/she expects confidentiality of resident records to be maintained.
2. Review of Resident #153's care plan, undated, showed the resident has a right to privacy and confidentiality.
Observation outside at back of facility on 9/23/24 at 11:57 P.M., showed a tipped over locked shred box laying on the ground behind the D hall unit. The shred box had visible documents including medication bubble packs with identifying information that belonged to the resident.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said resident information should be protected and he/she did not expect resident information to be visible and exposed at the back of the facility building.
MO241172
MO241359
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and im...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for two sampled residents (Resident #153 and #52 ) out of 21 sampled residents. The facility census was 104.
Review of the facility provided policy Comprehensive Care Plans, dated 9/1/21 showed:
-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident; to meet the resident's medical, nursing, and mental and psychological needs identified in the resident's assessment.
-The comprehensive care plan will describe, at a minimum: services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing; Any specialized services; and the resident's goals.
1. Review of Resident #153 Initial Activity Assessment completed on 11/8/21 showed he/she liked:
-visits with family/friends;
-poker;
-gardening/outdoor activity;
-movies/tv;
-music/talk radio;
-pet visits;
-smoking.
Review of the resident's Face Sheet showed an initial admission date of 11/3/21 and a readmission date of 7/5/24.
Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff) dated 7/12/24 showed:
-Brief Interview of Mental Status of 99; indicated severe cognitive deficit;
-Daily preference not completed;
-Activity preference not completed;
-He/she was dependent on staff for all cares;
-Use of Foley catheter (a sterile tube inserted into the bladder to drain urine);
-Nutrition via tube (he/she is fed through a tube surgically implanted in his/her stomach);
-Nothing by mouth;
-He/she had a tracheostomy (a surgical opening into the neck and windpipe, fitted with a plastic tube, to allow air to fill the lungs);
-He/She did not speak;
-Diagnoses of Respiratory Failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood), Encepholopathy (brain disease that alters brain function or structure), Need for assistance with personal care, and Chronic Obstructive Pulmonary Disease (COPD:common lung disease causing restricted airflow and breathing problems).
Review of the resident's physician order sheets for September 2024 showed:
-Complete tube site care, every hour as needed, cleanse with soap and water, apply a dry dressing if indicated. Monitor for signs and symptoms of infection;
-Change inner tracheostomy cannula every day and as needed, change the cannula anchor weekly and as needed.
Review of Resident #153's Comprehensive Care Plan dated 7/19/24 showed:
-The resident has little or no activity involvement;
-The resident will express satisfaction with type of activities and level of activity involvement when asked through the review date;
-No care plan for activity preferences;
-No care plan for use and care of the tracheostomy.
2. Review of Resident #52's admission MDS dated [DATE], showed:
-His/Her cognitive status was undetermined;
-He/She had no speech;
-He/She rarely or never understand others;
-He/She had adequate vision;
-He/She did not wear corrective lenses;
-He/She had limited range of motion in upper and lower extremities on both sides;
-He/She was dependent on a wheelchair for mobility;
-He/She was dependent for all cares and mobility;
-Diagnoses included anxiety disorder, aphasia (a language disorder that affected a person's ability to understand and express language, as well as read and write), depression, and respiratory failure.
Review of resident's face sheet, showed:
-He/She was admitted to facility on 7/23/24.
Review of the resident's care plan, dated 7/31/24, showed:
-Encourage social interactions and participation in activities with others that have similar interests;
-Provide emotional and spiritual support for resident and/or family/guardian decisions as needed;
-He/She had no activity preferences care planned.
3. During an interview on 9/23/24 at 3:33 P.M., Administrator said:
-He/She expected one on one activities to be care planned;
-He/She expected a tracheostomy to be care planned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based observation, interview, and record review, the facility staff failed to follow physician's orders and apply a resident's cervical collar (neck brace) as ordered daily for one resident (Resident ...
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Based observation, interview, and record review, the facility staff failed to follow physician's orders and apply a resident's cervical collar (neck brace) as ordered daily for one resident (Resident #52) who was dependent upon staff for mobility and assistance with care. This affected one of twenty-one sampled residents. The facility census was 104.
Review of facility policy, provision of physician ordered services, dated 2022, included professional standards of quality means that care and services are provided according to accepted standards of clinical practice.
1. Review of Resident #52's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/26/24, showed:
-His/Her cognitive status was not testable;
-He/She had no speech;
-He/She rarely or never understand others;
-He/She had limited range of motion in upper and lower extremities on both sides;
-He/She was dependent on a wheelchair for mobility;
-He/She was dependent for all cares and mobility;
-He/She had applications of ointments/medications for pressure ulcer;
-He/She was not on a turning/repositioning program;
-Diagnoses included: aphasia (a language disorder that affects a person's ability to understand and express language), muscle weakness, lack of coordination, epilepsy (a chronic brain disorder that causes seizures, which are brief episodes of involuntary movement or altered consciousness), and retts syndrome (a rare genetic disorder that affects the brain and causes a loss of skills and abilities).
Review of the resident's physician's orders, dated 9/17/24, showed:
-An order dated 9/5/24, for occupational therapy to provide a soft cervical collar and right hand palm guard splint. Splinting schedule posted above patient head of bed. Cervical collar to be worn during day and doffed each night with skin checks. Palm guard to be worn at all times except for daily hand hygiene. One time for six weeks.
Review of the resident's care plan, revised 9/16/24, directed staff to administer treatments as ordered and monitor for effectiveness.
During an interview on 9/16/24 at 7:30 P.M., the resident's representative said:
-The resident wore a neck brace due to severe contracture;
-The neck brace was excessively dirty;
-He/She was also to wear hand brace on right hand.
Observation of the resident on 9/16/24 at 7:30 P.M. showed:
-His/her right hand brace was on;
-He/she was not wearing a neck brace. The neck brace was laying on bedside table;
-The neck brace had discoloration to the white and showed black and brown discoloration appearing dirty.
Observation on 9/17/24 at 9:45 A.M., showed the resident laying in bed, he/she did not have on a cervical collar. The Cervical collar was observed on the bedside table.
Observation on 9/17/24 at 11:09 A.M., showed resident did not have on cervical collar. The cervical collar was on the bedside table.
Observation on 9/17/24 at 11:47 A.M., showed resident's cervical collar had not been applied as ordered. The cervical collar remained on bedside table. The collar was noted to be dirty with discoloration of dirt and brown like substance on white color.
Observation on 9/17/24 at 1:25 P.M., showed resident's cervical collar was on bedside table noted with brown discoloration and dirt.
Observation on 9/18/24 at 8:00 A.M., showed resident did not have on cervical collar. A sign above resident's bed directed staff to put the cervical collar on the resident in morning and place the palm protector on the residents hand during the day and leave it off at bedtime.
Observation on 9/19/24 at 12:18 P.M., showed the resident without a cervical collar.
Observation on 9/19/24 at 2:09 P.M., showed Occupational Therapy in resident's room providing therapy.
Observation on 9/19/24 at 5:39 P.M., showed resident laying in bed with his/her cervical collar on.
During an interview on 9/19/24 at 2:09 P.M., Occupational Therapist said:
-The resident was supposed to have his/her cervical collar on;
-He/She thought the cervical collar had been taken to be washed due to excessive dirt on the collar.
During an interview on 9/23/24 at 10:05 A.M., Registered Nurse A said:
-The resident was supposed to have cervical collar on at all times;
-Last week there were a few days when the resident had been without his/her cervical collar and he/she believes that was because it had been taken to be washed.
During an interview on 9/23/24 at 3:33 P.M., the Director of Nursing said:
-He/She expected staff to follow the residents physician's orders unless a resident refused;
-A resident who refused cares or should be documented in the residents chart.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said he/she expected staff to follow the physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent flies and roaches. The facility census was 114.
Review of the facility ...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent flies and roaches. The facility census was 114.
Review of the facility provided Pest Control Policy dated 9/1/22 showed:
-It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents
-The facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the pest service and state and federal regulations.
Observations beginning on 09/16/24 at 12:58 P.M. on [NAME] Hall showed:
-Large cobwebs with dead bugs at the corner of the exit door.
-Multiple flies in room B1.
Review of Resident #52's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/26/24, showed:
-His/Her cognitive ability was not testable;
-He/She had no speech;
-He/She rarely or never understand others;
-He/She had limited range of motion in upper and lower extremities on both sides;
-He/She was dependent on a wheelchair for mobility;
-He/She was dependent for all cares and mobility;
-Diagnoses included: aphasia (a language disorder that affects a person's ability to understand and express language), muscle weakness, lack of coordination, epilepsy (a chronic brain disorder that causes seizures, which are brief episodes of involuntary movement or altered consciousness), and Retts syndrome (a rare genetic disorder that affects the brain and causes a loss of skills and abilities).
Observation on 9/16/24 at 7:26 P.M. showed:
-He/She had flies flying around his/her room;
-There were two sticky fly traps hanging on the wall above resident's bed.
During an interview on 9/16/24 at 7:26 P.M. the resident representative said:
-The resident had excessive flies in his/her room;
-The flies would land on the resident's face and he/she could not swat them away;
-Flies in the room have been a problem since admission;
-He/She purchased fly strips to hang in the resident's room to combat the problem.
During an interview on 9/23/24 at 9:11 A.M. the Maintenance Director said:
-Pest control is completed by an outside company.
During an interview on 9/23/24 at 3:33 P.M. the Administrator said:
-He/She was aware there were flies in the facility.
-He/She expected the facility to be as free of pests as possible.
-There is an outside company for pest control.
-The outside company comes monthly to check and spray for pests.
The facility did not provide pest control invoices.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior throughout the facility. Additionally, the facility failed to ensure furnishings were in good repair. The facility census was 104.
Review of the facility provided policy Routine Cleaning and Disinfection dated 9/1/21 showed:
-It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment;
-Cleaning refers to the removal of visible soil from objects and surfaces;
-Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine areas should be cleaned on a regular basis; when soiling or spills occur; when a resident is discharged ;
-Cleaning of walls, blinds and window curtains will be conducted when visibly soiled.
Review of the facility provided, undated, policy Safe and Homelike Environment included, in accordance with resident rights the facility will provide a safe, clean, comfortable and homelike environment.
Observation on 09/18/24 at 8:03 A.M. showed the special care unit with a strong odor of urine.
Observation on 09/18/24 at 12:33 P.M. showed on the Special Care Unit:
-Resident room [ROOM NUMBER]A, the baseboards peeled away from the wall, had a strong odor of urine, and the entry door had multiple scuff marks;
-Resident wheelchairs with torn arm rests, exposing foam underneath;
-Resident wheelchairs with dirt and debris, caked on the metal frames, seats and cushions.
During an interview on 9/19/24 at 11:33 A.M., Physical Therapy Assistant A said:
-He/She tells the Central Supply Manager when a new wheelchair or part is needed;
-The facility was aware there were wheelchairs in disrepair.
During an interview on 9/19/24 at 11:33 A.M. the Director of Physical Therapy (PT) said:
-He/She had placed an order for 20 new wheelchairs from central supply recently;
-PT is in charge of ensuring all wheelchairs are in good repair and working order.
During an interview on 9/19/24 at 11:33 A.M. the Central Supply Manager said:
-He/She had not ordered any wheelchairs since January 2024;
-Therapy will let him/her know if wheelchairs or parts are needed;
-If a wheelchair is torn and foam is showing a new one needs ordered;
-He/She has not had any recent orders for new wheelchairs.
During an interview on 9/19/24 at 11:33 A.M. the Corporate Nurse said:
-The facility was aware wheelchairs needed to be replaced;
-No one in the facility ensured a system was in place for replacing wheelchairs;
-There was a system breakdown in this area.
Observations beginning on 09/16/24 at 12:58 P.M. on [NAME] Hall showed:
-Multiple room doors with scratches and nicks in the kick plate.
Observation on 9/23/24 at 11:26 A.M. showed:
- Room A20 privacy curtain had multiple stains and small tears. The second curtain was missing multiple hooks;
-Room A22 privacy curtain had a hole in the mesh at the top of the curtain;
-Room A23 privacy curtain had stains and small tears over the curtain;
-Room A18 privacy curtain had holes in the mesh at the top of the curtain.
Observation on 9/16/24 at 9:36 A.M., showed dirty dishes sitting in the common area between the [NAME] and Maple halls. No residents present.
Observation on 9/16/24 at 10:13 A.M., showed room A-1 on Maple hall had caked on dirt and food with sticky spots on the floor. Chew spit was also observed on floor of resident's room.
Observation on 9/16/24 at 6:55 P.M., showed dead bugs in base of holder of hand sanitizer dispensers on Maple hall.
Observation on 9/17/24 at 6:59 A.M., showed a strong odor of urine in hallway by the nurses station on Maple hall.
During an interview on 09/23/24 at 7:33 A.M., Housekeeper A said:
-He/She completed daily cleaning of the resident bathrooms and mops the floor;
-One person cannot complete everything that needed to be completed;
-There is a floor technician in the evening to buff floors;
-There was no check off list for completed tasks.
During an interview on 09/23/24 at 8:17 A.M., the Housekeeping Supervisor said:
-The Administrator expects the facility to be clean and odor free;
-Cleaning is completed daily by a list;
-He/She expects the facility to be clean, odor free and floors and ceilings to be free of dirt and debris.
During an interview on 9/23/24 at 9:11 A.M., the Maintenance Director said:
-He had been employed in the facility four months;
-Morning meetings are where he finds out repairs that are needed, or staff can fill out a work order;
-He completed weekly walk through inspections with Administration;
-He expects things to be in good repair;
-The baseboards are paint stained. Housekeeping is responsible for cleaning baseboards;
-Repairs are prioritized by need;
-Housekeeping is responsible for all floors, dusting and baseboard cleaning;
-He used a log book to know what needs fixed. If it was not on the log then it would not be fixed;
-Log books were at each nurses station and any staff can write in them.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said:
-Housekeeping was to complete daily cleaning to include dusting and high dusting;
-She expected the facility to attempt to be odor free as much as possible;
-Vents, floors and ceilings should be cleaned by housekeeping and maintenance as a collaborative effort;
-Anyone can put a work order in if something is broken;
-Each Department Head completes weekly rounds and would make a note of any issues that need addressed by a different department;
-She would expect work orders to be completed if the department head found a concern for maintenance;
-They have made progress in the cleanliness of the building but had more to go.
MO#241807
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 provide assistance to dependent residents with groomi...
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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 assistance to dependent residents with grooming, and showers at least twice a week for nine of 21 sampled residents (Resident #12, #13, #14 #49, #67, #74, #80, #87, and #91). The facility failed to provide shaving assistance and nail care for one resident (Resident #14). The facility failed to provide incontinent care for two residents (Resident #13 and #80). The facility census was 104
Review of facility policy, Activities of Daily Living, dated 9/1/21, showed:
-The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable including ability to bathe, dress, groom, and toilet.
-The facility shall provide a maintenance and restorative program to assist the resident in maintaining the highest practicable outcome based on the comprehensive assessment.
-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Review of facility policy, resident showers, dated 9/1/21, showed:
-It was practice of facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.
-Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.
Review of facility policy, Bathing a Resident, dated 9/1/21, showed:
-It was practice of facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.
1. Review of Resident #12's, quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/6/24, showed:
-He/She was cognitively impaired;
-He/She had moderate difficulty with hearing, speaker has to increase volume and speak distinctly;
-He/She had clear speech and was able to make self understood and understand others;
-He/She had no impairment to upper or lower extremities;
-He/She was dependent on a walker/wheelchair;
-He/She required supervised or touching assistance with bathing, sit to stand and chair to bed transfers;
-Diagnosis included lack of coordination, difficulty walking, muscle weakness, unsteadiness on feet, depression, bipolar disorder (mental illness that causes extreme mood swings).
Review of care plan, revised 9/1/24, showed:
-He/She had an ADL self-care performance deficit due to stroke and chronic obstructive pulmonary disease (COPD);
-Resident required assistance from one staff with showering twice weekly and as necessary;
-Check nail length and trim and clean on bath day and as necessary;
Observation on 9/16/24 at 10:06 A.M. showed:
-Resident's hair was greasy and had not been brushed;
-He/She had long nails with black/brown color underneath his/her nail bed.
During an interview on 9/16/24 at 10:06 A.M., the resident said:
-He/She did not get showers or baths when he/she wanted them;
-He/She had gone 7-8 days without a shower;
-He/She wanted a shower twice a week on Mondays and Fridays;
-He/She had scheduled shower days but he/she never got showers on his/her scheduled shower days;
-He/She was lucky because he/she got one shower on Saturday during the past week.
Review of shower schedule, dated 4/30/24, showed Resident #12's room number had shower days on Monday and Thursdays.
Review of shower sheets, dated 6/1/24 to 9/17/24 , showed:
-He/She received one shower out of five scheduled opportunities in September on 9/17/24, which was nineteen days from his/her last prior shower in August;
-He/She received five showers in August on 8/1, 8/7, 8/13, 8/26, and 8/29 out of nine scheduled opportunities;
-He/She received four showers in July on 7/2, 7/9, 7/19, and 7/23 out of nine scheduled opportunities;
-He/She received three showers in June on 6/17, 6/20, and 6/26 out of eight scheduled opportunities.
2. Review of Resident #49's quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had clear speech, and was able to make self-understood and understand others;
-He/She felt down, depressed or hopeless half or more days;
-He/She had no behavioral symptoms or rejection of care;
-He/She had impairment on one side of upper and lower extremities;
-He/She was dependent on walker and wheelchair;
-He/She required substantial/maximal assistance with bathing
-He/She was frequently incontinent;
-Diagnoses included stroke (condition causing damage to the brain from an interruption of its blood supply), hemiplegia (condition causing weakness on one side of the body), heart failure, high blood pressure, diabetes (too much sugar in the blood), depression, post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, lack of coordination, pain in left shoulder, need for assistance with personal care, osteoarthritis of the right shoulder (a chronic joint disease that causes the cartilage in one or more joints to break down over time).
Review of the resident's care plan, revised 7/30/24, showed:
-He/She had an ADL self-care performance deficit due to hemiplegia;
-He/She required extensive assistance with one person assist for shower twice weekly and as necessary;
-He/She required assistance washing under his/her arm, abdominal folds, and lower body;
-He/She had a rash under breast and pannus due to moisture;
-Preventive skin care as ordered, keep area under breast and pannus clean and dry.
During an interview on 9/16/24 at 6:24 P.M., the resident said:
-Showers were very infrequent;
-The last shower he/she had was less than a week ago and the shower prior to that was about 2 weeks in between showers;
-Not having showers regularly made him/her feel dirty and disgusting;
-Prior to his/her stroke he/she was taking two or three showers a day;
-He/She would like to receive at minimum of two showers a week;
-He/She was scheduled to have showers on Tuesdays and Fridays but he/she rarely received showers as scheduled;
Review of shower schedule, dated 4/30/24, showed Resident #49's room number had showers scheduled on Mondays and Thursdays.
Review of shower sheets, dated 6/1/24 to 9/17/24 , showed:
-He/She received one shower in September on 9/5 out of five scheduled opportunities;
-He/She received two showers in August on 8/6 and 8/21 out of nine scheduled opportunities;
-He/She received two showers in July on 7/9 and 7/21 out of nine scheduled opportunities;
-He/She received two showers in June on 6/15 and 6/25 out of eight scheduled opportunities
-He/She received a shower 7 out of 31 opportunities from June to September.
3. Review of Resident #87's quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had clear speech, was able to make self-understood, and understand others;
-He/She had impairment on one side of upper extremity, and impairment on both sides of lower extremities;
-He/She was dependent on a wheelchair;
-He/She was dependent for bathing and tub transfers;
-Diagnosis included traumatic spinal cord dysfunction, central cord syndrome as an after effect of disease, condition, or injury at the fifth cervical vertebra level of the cervical spinal cord (type of incomplete spinal cord injury characterized by weakness, loss of sensation below injury site, loss of bladder control, pain such as tingling and burning), paraplegia (paralysis of legs and lower body caused by spinal injury), spinal stenosis in cervical region (a chronic condition that occurs when spinal canal narrows, putting pressure on spinal cord and nerve roots), muscle weakness, and difficulty walking.
Review of the resident's care plan, revised 1/31/24, showed:
-Resident had an ADL self-care performance deficit.
-He/She was dependent on two staff for transfers from chair to bed, and shower;
-He/She required set up, supervision, and physical assistance to maintain personal hygiene.
-Revision 7/5/24 showed patient refused shower that morning because he/she said shower aide was a witch and that his/her potions and lotions cause him/her to burn and itch.
During an interview on 9/16/24 at 10:40 A.M., the resident said:
-He/She received a shower one time every two weeks;
-He/She felt like garbage when he/she had to go so long without showers;
-He/She had a shower on 9/14, prior to that his/her last shower was two weeks prior;
-He/She would like to have a shower every day;
-He/She completed his/her own shaving.
Review of the shower schedule, dated 4/30/24, showed Resident #87's room number had assigned shower days on Wednesday and Saturdays.
Review of shower sheets, dated 6/1/24 to 9/17/24 , showed:
-He/She had no documented showers in September out of four opportunities, and he/she had one documented refusal on 9/17/24;
-He/She received three showers in August on 8/7, 8/17, and 8/31 out of nine scheduled opportunities, with no documented refusals;
-He/She received two showers in July on 7/3 and 7/7 out of nine opportunities with 2 refusals on 7/19 and 7/24.
-He/She received three showers in June on 6/5, 6/19, and 6/26 out of nine scheduled opportunities, no documented refusals;
-He/She received 8 out of 31 opportunities for showers, and 3 refusals out of 31 scheduled opportunities for showers.
During an interview on 9/16/24 at 12:11 P.M., Certified Nurse Aide (CNA) A said:
-He/She was a shower aide, but he/she was pulled from completing showers to work the floor all the time;
-Residents go without showers for much longer than a week at a time;
-He/She has given showers and the white towels will be black.
During an interview on 9/16/24 at 7:48 P.M., Certified Medication Technician (CMT) A said:
-Showers were not getting done;
-The hall had only one Certified Nurse Aide scheduled;
-Staffing is an issue which has resulted in patient care not getting done.
-the shower aide was constantly pulled to floor to work as a CNA, so showers were not getting completed.
During an interview on 9/23/24 at 10:05 A.M., Registered Nurse (RN) A said:
-Showers are a problem throughout the facility, not just on one hall.
-Showers are not done due to insufficient staff.
During an interview on 9/23/24 at 3:33 P.M., Administrator said:
-Residents should be offered showers at a minimum of one time a week but facility goal was to offer twice weekly;
-He/She expected same for resident's nail care, hair care, and shaving.
-There had been time goal had not been met due to staffing in facility.
4. Review of Resident #13's care plan revised, 3/27/24, showed:
-The resident has an ADL self care performance deficit;
-The resident is dependent on staff for toileting;
-Clean peri-area after each incontinent episode;
-The resident has the potential for pressure ulcer development related to incontinence;
-The resident requires total assistance of one staff for transfers;
-The resident has the right to be treated with dignity.
Review of the resident's quarterly MDS dated , 6/20/24, showed:
-Severe cognitive impairment;
-Dependent on staff for Activities of ADLs;
-Incontinent of bowel and bladder;
-Diagnoses included, dementia, high blood pressure and anxiety.
Continuous observation beginning on 09/16/24 at 09:20 A.M., showed:
-09:20 A.M., the resident sat at the table in the dining room in his/her wheelchair;
-10:13 A.M., the resident sat at the table in the dining room in his/her wheelchair. Facility staff had not offered to toilet the resident;
10:59 A.M. the resident sat in his/her wheelchair at the table, with his/her eyes closed;
-11:03 A.M., the resident sat in his/her wheelchair at the table. LPN B walked by the resident and did not provide incontinent care for the resident;
-11:25 A.M., CNA D walked by the resident who sat in his/her wheelchair at the table CNA D did not offer to provide incontinent care for the resident;
-12:26 P.M., lunch was delivered to the memory care unit. The resident sat in his/her wheelchair at the table with his/her eyes closed;
-12:42 P.M., Lunch was delivered to the resident at the table, while he/she sat in his/her wheelchair;
-12:46 P.M., No staff offered to reposition or toilet the resident;
- 01:01 P.M., The resident finished his/her lunch and sat in his/her wheelchair at the table. No staff provided incontinent care for the resident;
-01:25 P.M., the resident sat at the table in his/her wheelchair. No staff had toileted the resident.
Observation on 09/17/24 at 05:22 A.M., showed:
-The resident's room had a strong smell of urine;
-CNA D changed the resident's brief;
-The resident's brief was saturated with a yellow substance and smelled of urine;
-CNA D performed perineal care and applied a new brief.
Continuous observation beginning on 09/17/24 at 05:39 A.M., showed:
-05:39 A.M., the resident sat at the table in the dining room in his/her wheelchair;
-06:15 A.M., the resident sat at the table in the dining room in his/her wheelchair. No staff offered to toilet the resident;
-07:30 A.M., the resident sat in his/her wheelchair at the table;
-08:30 A.M., the resident sat at the table in the dining room in his/her wheelchair;
-09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair. No staff offered to toilet the resident.
5. Review of Resident #67's annual MDS dated , 7/17/24, showed:
-Moderate cognitive impairment;
-Visual impairment;
-Substantial assistance from staff for toileting;
-Supervision of staff for dressing;
-Incontinent of urine;
-Diagnoses included, stroke, depression, high blood pressure and cataracts (a clouding of the eye's lens that can lead to vision loss).
Review of Resident #67's undated care plan showed:
-The resident has an ADL self care performance deficit;
-The resident requires supervision for dressing;
-The resident requires supervision with personal hygiene;
-The resident requires assistance with toileting;
-The resident has the right to be treated with dignity.
Observation on 09/16/24 at 09:50 A.M., showed:
-The resident walking into the dining room;
-The resident's hair was unkempt and his/her glasses had white specks on the lenses;
-The resident's pants and shirt had black stains on them.
Observation on 09/16/24 at 12:24 P.M., showed:
-The resident sat in the dining room at a table;
- The resident's glasses had white specks on the lenses;
-The resident's hair was unkempt and his/her clothes had black stains on them.
Observation on 09/17/24 at 08:01 A.M., showed:
-The resident sat in the dining room;
-The resident wore the same clothes as 9/16/24;
-The resident's pants and shirt had black stains on them.
-The resident's hair was unkempt and his/her glasses had white specks on the lenses.
6. Review of Resident #80's care plan revised, 6/13/24,showed:
-The resident has an ADL self care performance deficit;
-The resident requires total assistance of one to two staff for showers and toileting;
-The resident requires total assistance of one to two staff for transfers;
-The resident has impaired cognitive function related to dementia;
-The resident has the right to be treated with dignity;
-The resident has the right to privacy and confidentiality.
Review of the resident's quarterly MDS dated [DATE], showed:
-Severe cognitive impairment;
-Dependent on staff for Activities of Daily Living (ADLs);
-Incontinent of bowel and bladder;
-Diagnoses included, dementia, high blood pressure and anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues).
Continuous observation beginning on 09/16/24 at 09:20 A.M., showed:
-09:20 A.M., the resident sat at the table in the dining room in his/her wheel chair;
-10:13 A.M., the resident sat at the table in the dining room in his/her wheel chair. No staff offered to toilet the resident;
-10:59 A.M. the resident sat in his/her wheel chair at the table with his/her eyes closed;
-11:03 A.M., the resident sat in his/her wheel chair at the table. LPN B walked by and did not provide incontinent care for the resident;
-11:25 A.M., CNA D walked by the resident setting in his/her wheel chair at the table and did not offer to provide incontinent care for the resident;
-12:26 P.M., lunch was delivered to the memory care unit and the resident still sat in his/her wheel chair at the table with his/her eyes closed;
-12:42 P.M., lunch was delivered to the resident and he/she sat at the table in his/her wheel chair;
-12:46 P.M., no staff had repositioned or toileted the resident;
- 01:01 P.M., the resident finished his/her lunch and sat in his/her wheel chair at the table. No staff provided incontinent care for the resident;
-01:25 P.M., the resident sat at the table in his/her wheel chair with his/her eyes closed. No staff toileted the resident.
Continuous observation beginning on 09/17/24 at 05:39 A.M., showed:
-05:39 A.M., the resident sat at the table in the dining room in his/her wheel chair;
-06:15 A.M., the resident sat at the table in the dining room in his/her wheel chair. No staff offered to toilet the resident;
-07:30 A.M., the resident sat in his/her wheel chair at the table. The DON delivered breakfast to him/her and did not offer to reposition or toilet the resident;
-08:30 A.M., the resident sat at the table in the dining room in his/her wheel chair;
-09:30 A.M., LPN B said good morning to the resident, but did not offer to toilet the resident.
During an interview on 9/18/24 at 1:14 P.M., CNA D said:
-He/she tries to toilet incontinent residents at least every two hours;
-It gets busy sometimes and he/she does not have time;
-Incontinent residents should be toileted at least every two hours.
During an interview on 9/18/24 at 1:28 P.M., LPN B said:
-The CNAs usually toilet the residents;
-He/she expects the residents to have incontinence care every two hours or as needed;
-He/she was not aware the incontinent residents had not been toileted for over two hours;
-Incontinent residents should be toileted at least every two hours.
During an interview on 9/18/24 at 1:42 P.M., the DON said
-He/she expects residents to have incontinence care every two hours or as needed;
-He/she was not aware the incontinent residents had not been toileted for over two hours;
-He/she expects incontinent residents be provided peri care and changed at least every two hours.
7. Review of Resident #14's quarterly Minimum Data Set (MDS), dated , 7/22/24, showed:
-Brief interview for mental status (BIMS) score of 13, indicating the resident was not cognitively impaired;
-Partial/moderate assistance for oral care, toileting, showering, lying to sitting on side of bed, transfers to/from bed
-Supervision for dressing, personal hygiene, sit to stand, toilet transfer;
-Utilizes a walker for mobility;
- Occasionally incontinent of urine, always continent of bowel;
- Diagnoses included Parkinson's Disease (brain disorder affecting body movements), hypertension (high blood pressure), diabetes (chronic disease of the Pancreas).
Review of the resident's care plan, dated 3/28/24, showed:
- The resident has an ADL self-care performance deficit. Impaired mobility, cognition impaired, memory impaired, impaired eyesight that may worsen;
-Resident needs cues and supervision with all self care. Resident sometimes requires more physical assistance when feeling weaker than normal or is having tremors.
-Personal Hygiene: The resident requires supervision and periodic assist with set up by (1) staff with personal hygiene and oral care. Resident needs staff to comb hair and to shave.
Observation on 9/17/24 at 11:42 A.M., showed, Resident #14 had long hair, their nails were long, his beard growth was uneven and about one half inch long.
During an interview on 9/17/24 at 11:42 A.M., Resident #14 stated his last shower was two weeks ago. He prefers a shower every day but getting one every other week right now. The resident said he would like his beard shaved but he/she has no utensils to do it and needs staff to do this for them. He can't remember his last shave but it's been a while. He also would like his nails cut and they hurt sometimes because they are so long,. Staff told him/her they did not have the tools to cut his/her nails.
Observation on 9/18/24 at 11:40 A.M., showed Resident #14 still long nails and no hair cut and beard was not shaved.
Interview on 9/23/24 at 3:30 P.M., Administrator and Director of Nursing (DON) stated:
-Expectations for resident grooming is that they receive a shave, fingernails cut, clean appearance and odor free clothes;
-Residents are offered and receive showers twice a week. The goal is to bathe residents twice a week, and provide some nail and hair care as well. There have been times when they have not met that goal, but they try their best on the floor.
8. Review of Resident #74's admission MDS assessment, completed by facility staff, dated 9/10/24, showed:
-He/She was cognitively intact;
-Always incontinent of both bowel and bladder;
-Diagnoses included brain disease; shortness of breath; urinary tract infection; kidney disease; asthma; heart disease; depression; osteoarthritis; malnutrition.
Review of the undated care plan, showed:
-Resident's autonomy and dignity will be honored in the personal choices they make;
-Resident had an ADL (activities of daily living self-care) performance deficit;
-Resident was at risk for falls.
Review of progress notes dated 9/14 showed:
-Resident continued ABT (antibiotic therapy) for UTI (urinary tract infection) with no adverse drug reaction (ADR) noted. Fluids encouraged while awake.
Review of progress notes dated 9/15 showed:
-Resident remained on ABT/UTI without any adverse reaction.
Review of Progress notes dated 9/16 showed:
-Resident continued ABT/UTI with no adverse reaction. Resident was incontinent with some control. Assist of one with toileting and cares. Fluids encouraged while awake.
Review of progress notes, dated 9/17, showed:
-Continued Cipro (antibiotic) for UTI; encouraged to increase water intake.
Observation and interview on 09/16/24 09:59 A.M. showed:
-Resident sat on the bed in a hospital gown. The resident stated he/she had been waiting since 8:30 A.M. and expressed frustration that he/she was not dressed yet.
-Resident stated he/she often doesn't get help to the bathroom in time and sometimes soils himself/herself while waiting for assistance.
During an interview on 09/17/24 at 11:19 A.M., the resident's daughter said:
-She is concerned the resident has not had a bath since he/she was admitted (admit date : [DATE]) and said the resident has started scratching at his/her head due to his/her hair and scalp being dirty.
Observation and interview on 09/23/24 at 09:13 A.M. showed the resident unshaven and stating he/she asked several days ago for assistance. He/she said there is not enough staff at the facility to help the resident shave.
During an interview on 09/18/24 at 03:35 P.M., Nurse B said the resident shaving/shower schedule depends on resident preference vs. resident schedule and there are residents that are scheduled for twice a week.
During an interview on 09/19/24 at 07:08 A.M. CNA B said he/she checks on the resident every couple of hours to see if he/she needs to use the bathroom and the resident uses a urinal.
9. Review of Resident #91's annual minimum data set assessment (MDS), completed by facility staff, dated 7/10/24, showed:
-Resident is cognitively intact;
-Diagnoses include anemia, heart failure, hip fracture, high blood pressure, kidney failure, urinary blockage, arthritis, lung disease, blood clot in lung.
-Resident requires substantial assistance to maintain personal hygiene.
-Resident is completely dependent on assistance with toileting and bathing.
Review of resident's care plan, dated 4/19/24 showed:
-Check resident every two hours and assist with toileting as needed.
-Clean peri-area with each incontinence episode.
During an interview on 09/16/24 at 10:39 A.M., the resident said:
-He/she often waits an hour for call light to be answered to be changed.
-He/she prefers to get up by 8:00 A.M. but frequently does not get assistance to get up until 11:00 A.M.
During an interview on 09/19/24 at 07:08 A.M., staff said:
-CNA B asks residents if they want to get up to get dressed for the day.
-CNA C said that it is up to the resident to decide what time they want to get up.
During an interview at 09/23/24 at 03:36 P.M., the DON (director of nursing) said:
-To ensure residents hydration needs are met, staff are to make ensure each resident's cup is full of fluid and is being offered more than two hours.
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 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 activities program to support 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 activities program to support the needs of three of 21 sampled residents (Resident #153, #93, and #52). The facility census was 104.
Review of the facility provided policy, Activities, dated 9/1/21 showed:
-It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical,mental and psychological well being of each resident.
-Activities refer to any endeavor, other than routine ADLs(Activities of Daily Living: tasks completed in a day to care for oneself, such as using the toilet, bathing, nail care, brushing hair and teeth.)in which the resident participates that is intended to enhance his/her sense of well being and to promote or enhance physical, cognitive and emotional health.
-Activities will be designed with the intent to:
-Enhance the resident's sense of well-being, belonging and usefulness;
-Promote or enhance physical activity;
-Promote or enhance cognition;
-Promote or enhance emotional health;
-Promote self esteem, dignity, pleasure, comfort, education, creativity, success and independence;
-Reflect the resident's interests and age;
-Reflect cultural and religious interests;
-Reflect choices of the residents.
-Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs.
1. Review of Resident #153's Initial Activity Assessment completed on 11/8/21, showed he/she liked:
-visits with family/friends;
-poker;
-gardening/outdoor activity;
-movies/tv;
-music/talk radio;
-pet visits;
-smoking.
Review of the resident's face sheet showed an initial admission date of 11/3/21 and a readmission date of 7/5/24.
Review of the resident's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 7/12/24 showed:
- Brief Interview of Mental Status of 99; indicated severe cognitive deficit;
-Daily preference not completed;
-Activity preference not completed;
-He/she was dependent on staff for all activities of daily living (ADLs: tasks completed in a day to care for oneself);
-Use of foley catheter (a sterile tube inserted into the bladder to drain urine);
-Nutrition via tube (Gastrostomy: a tube surgically implanted in his/her stomach to provide liquid nutrition);
-Nothing by mouth;
-He/she had a tracheostomy (a surgical opening into the neck and windpipe, fitted with a plastic tube, to allow air to fill the lungs);
-He/She did not speak;
-Diagnoses of Respiratory Failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood), Encepholopathy (brain disease that alters brain function or structure), Need for assistance with personal care, Chronic Obstructive Pulmonary Disease (COPD:common lung disease causing restricted airflow and breathing problems).
Review of Resident #153 Comprehensive Care Plan dated 7/19/24 showed:
-The resident has little or no activity involvement;
-He/she prefers television drama and sports;
-The resident will express satisfaction with type of activities and level of activity involvement when asked through the review date.
-No care plan for activity preferences.
Review of the resident's record of activities for July 2024 showed:
-5th: the resident met with his/her brother, marked as a 1:1 visit;
-8th: music therapy and staff combed his/her hair;
-10th: staff provided nail care;
-12th: church on television;
-15th: music therapy;
-17th: staff provided nail care;
-20th: church music played;
-22nd: rock music played;
-24th: staff provided nail care;
-26th: church on television;
-28th: music played ;
-30th: staff provided nail care.
Review of the resident's record of activities for August 2024 showed:
-5th: staff talked to him/her a bit;
-8th: staff talked to him/her while the foot doctor worked on his/her feet;
-10th: television was playing a show;
-12th: staff went to talk to him/her;
-14th: some peers visited him/her;
-16th: music was on, and staff said good morning;
-18th: television was playing the weather;
-21st: staff saw him/her and checked his/her nails;
-24th: staff turned television to music;
-28th: staff put on rock and roll music;
-30th: television playing.
Review of the resident's record of activities for September 2024 showed:
-1st: staff turned on music and gave him/her a hand massage;
-3rd: staff combed his/her hair and talked about leaves falling;
-5th:sleeping;
-7th:sleeping;
-8th to the 13th he/she was hospitalized .
Observations showed:
-On 9/17/24 at 5:15 A.M., the resident was in bed; his/her television on without sound;
-On 09/17/24 at 9:08 A.M., he/she was in bed; his/her television on without sound;
-On 09/18/24 at 10:26 A.M., he/she was in his/her room, in bed, television on menu of available channels and without sound;
-On 09/18/24 at 2:24 P.M., he/she was in his/her room, in bed, television on menu of available channels and without sound. Live music program was in the dining room.
2. Review of Resident #93 Quarterly MDS dated [DATE] showed:
-BIMS of 99; indicated significant cognitive impairment;
-He/She was dependent on staff for all ADLs;
-Use of foley catheter;
-Nutrition via tube (Gastrostomy: a tube surgically implanted in his/her stomach to provide liquid nutrition);
-Nothing by mouth;
-He/she had a tracheostomy (a surgical opening into the neck and windpipe, fitted with a plastic tube, to allow air to fill the lungs);
-Diagnoses of Nontraumatic Intracerebral Hemorrhage in the Brain Stem (a condition where blood pools in the brain stem after a stroke), Hemiplegia (muscle weakness or loss of movement on one side of the body), Tracheostomy , Gastrostomy, Cerebral Infarction (also known as a stroke: where blood flow to part of the brain is stopped, causing damage to the brain).
Review of the resident's Comprehensive Care Plan dated 7/22/24 showed:
-No care plan for activities.
Review of Resident #93's One to One Activity Record for July 2024 showed:
-3rd: staff talked about his/her new room;
-4th: staff went to read to him/her, the resident was asleep, popped in later and said hello;
-8th: he/she was asleep;
-11th: staff talked with him/her, he/she used his/her eyes to communicate;
-15th: staff read the chronicle to him/her;
-18th: he/she was asleep;
-20th: he/she was asleep;
-22nd: he/she was asleep;
-25th: he/she was watching TV and enjoyed it;
-29th: he/she was asleep.
Review of Resident #93's One to One Activity Record for August 2024 showed
-2nd: staff talked to him/her about getting new books;
-5th: staff asked him/her if he/she wanted a book read, he/she shook his/her head no;
-6th: he/she was asleep;
-8th: 8th: staff talked to him/her while the foot doctor worked on his/her feet;
-12th: he/she did not want to be read to;
-14th: he/she was asleep;
-16th: staff combed his/her hair, listened to music;
-18th: staff talked to him/her;
-21st: listened to music;
-24th: staff read a book to him/her;
-26th: he/she did not seem to want to wake up;
-28th: staff played music for him/her;
-30th: staff brushed his/her hair and told a story about staff members child.
Review of Resident #93's One to One Activity Record for September 2024 showed:
-1st: staff talked about children and start of school;
-3rd: staff massaged hands and cut fingernails;
-5th: staff brushed his/her hair and sang;
-7th: listened to music;
-9th: staff read a book;
-11th: listened to music;
-13th: he/she was sleeping;
-15th: staff read a book;
-17th staff massaged hands and fingernails.
Observation on 09/16/24 at 1:05 P.M. showed:
-The resident was in bed, faced toward TV with soap opera on. Hand written sign below the TV showed the resident likes: crime shows, documentaries, and a local football team.
Observation on 9/17/24 at 6:32 A.M. showed:
-The resident was in bed, turned away from the TV. The TV was on without sound.
Observation on 9/18/24 at 9:52 AM showed:
-The resident was in bed, turned toward the TV. The TV was on without sound.
Observation on 9/18/24 at 4:25 P.M. showed:
-The resident was in bed, turned toward the TV. The TV was on without sound.
3. Review of Resident #52's admission MDS dated [DATE], showed:
-His/Her cognitive status was undetermined;
-He/She had no speech;
-He/She rarely or never understand others;
-He/She had adequate vision;
-He/She did not wear corrective lenses;
-He/She had limited range of motion in upper and lower extremities on both sides;
-He/She was dependent on a wheelchair for mobility;
-He/She was dependent for all cares and mobility;
-Diagnoses included anxiety disorder, aphasia (a language disorder that affected a person's ability to understand and express language, as well as read and write), depression, and respiratory failure.
Review of resident's face sheet, showed:
-He/She admitted to facility on 7/23/24.
Review of the resident's care plan, dated 7/31/24, showed:
-Encourage social interactions and participation in activities with others that have similar interests;
-Provide emotional and spiritual support for resident and/or family/guardian decisions as needed;
-He/She had no activity preferences care planned.
Review of activities evaluation, dated 9/19/24, showed:
-He/She found strength in faith and religion and was of catholic affiliation;
-He/She enjoyed arts and crafts, going to the beauty/barber shop, community outings, education programs, exercise/sports, family/friend visits, parties/social events, pet visits, reading/writing, and religious activities;
-He/She loved rabbits;
-He/She enjoyed stuffed animal dolls but preferred them to be called dolls;
-He/She enjoyed bowling, gardening movies, television, music, talk radio;
-He/She enjoyed doing activities in his/her room and preferred one on one activities;
-He/She preferred to do activities in the afternoon or evening times;
-He/She could hear and loved being talked to.
Review of facility record of activities showed in July:
-On 7/23, he/she talked with his/her family when they visited;
-On 7/25, resident had a room visit and staff read a book;
-On 7/28, he/she received nails and hand massage.
Review of facility record of activities showed in August:
-On 8/5, staff went to talk to resident and got no response;
-On 8/16, resident listened to country music;
-On 8/18, resident was read a book;
-On 8/21, resident had his/her nails checked and staff talked with him/her;
-On 8/24, staff read a book to resident;
-On 8/26, staff talked to resident about his/her dolls;
-On 8/28, resident listened to country music;
-On 8/30, staff read resident a book.
Review of facility record of activities showed in September:
-On 9/1, resident listened to music and staff did his/her nails;
-On 9/3, resident was read a book and received a hand massage;
-On 9/5, music was played for resident;
-On 9/7, music was played for resident;
-On 9/9, resident was read a book;
-On 9/11, resident was sleeping and had music on;
-On 9/13, resident was sleeping and had music on and was read a book;
-On 9/15, resident had music on;
-On 9/17, resident was read a book.
Observation on 9/16/24 at 7:30 P.M. showed the resident awake and alert during a visit from family members. Resident was able to give family a thumbs up to acknowledge understanding and excitement. Family engaged with resident by turning on his/her radio, showing pictures on his/her phone, and talking about various family events. Resident had eye contact with family during their visit and seemed in tune to his/her surroundings.
Observation on 9/17/24 at 9:46 A.M-12:01 P.M., resident did not have any activity engagement. Activity staff went into room and told roommate about morning activity, but did not engage with resident.
Observation on 9/18/24 from 8:01 A.M.-11:58 A.M. showed no activity engagement with resident. RN A went into resident's room to provide tube feeding at 9:48 A.M. RN A replaced wash cloth, provided oral care, and gave medications. Resident rubbed head with arm.
Observation on 9/18/24 at 10:20 A.M. showed an activity calendar hanging on wall was from August- the calendar had not been updated to September. The resident was observed rubbing her head making motion like he/she wanted his/her head rubbed.
During an interview on 9/18/24 at 3:14 P.M., the MDS Coordinator said he/she wrote most of care plans but activities staff were supposed to complete their section.
During an interview on 9/23/24 at 10:43 A.M., the Activities Director said:
-Activity staff went into resident's rooms every other day;
-Staff will brush his/her hair or do residents nails;
-Resident #52's mother said resident #52 liked dolls so he/she sometimes put dolls and stuff on resident's bed;
-He/She has read children's book to residents;
-He/She has not turned on television for resident but he/she knew resident #52 liked cartoons;
-His/Her part time staff typically do the one on ones with residents;
-He/She had church services scheduled every Sunday;
-Activities should be care planned;
-He/She documented activities on activity sheets.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said:
-Activities calendars should be updated monthly;
-He/She expected one on one activities to be care planned;
-He/She expected one on one activities to be individualized.
MO#241359
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to employ a qualified activity professional to oversee the activity program for the facility. The designated employee was employe...
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Based on observation, interview and record review, the facility failed to employ a qualified activity professional to oversee the activity program for the facility. The designated employee was employed as the full time activity director for one year, however, had not completed an approved activity professional training program. The facility census was 104.
Review of the facility's Activity Director Qualifications, dated 2023, showed:
-Activity Director, at a minimum, shall meet the following qualifications:
-Licensed or registered by the state in which practicing;
-One or more of the following:
-Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990;
-Has 2 years of experience in a social or recreational program within the last 5 year, one of which was full-time in a therapeutic activities program;
-Is a qualified occupational therapist or occupational therapy assistant; or
-Has completed a training course approved by the state;
-Qualifications shall be verified prior to hire as Activity Director, and verified annually as part of the employee's performance appraisal process. Documentation of the employee's qualifications shall be maintained in the employee's personnel file;
-It is the responsibility of the employee to fulfill requirements for maintaining licensure or registration and providing the facility with documentation of renewals, revocations, surrenders, or suspensions of such licensure or registration.
Review of facility Activities Director job description, signed 6/3/24, showed:
- Accreditation as a certified activity director; completion of a state approved activity director training course;
-Bachelor's degree in recreation therapy or related area. Should be licensed or registered either nationally or by the state in which practicing;
-One year experience as an Activity Director in long term care;
-Two years of experience conducting social/recreational programs within the past five years, one of which was full time in a resident activities program in a health care setting;
-Attends and participates in scheduled training, educational classes, and meetings to maintain current certification as applicable. Attends and participates in in-service training as mandated by regulatory agencies and company policy.
Review of facility provided invoice, dated 8/12/24, showed:
-Missouri Health Care Association billed Activity Director on 8/12/24 for purchase of online activity director workshop and long term care for activity and social services textbook.
During an interview on 9/23/24 at 11:10 A.M., the Activity Director said:
-He/She had not been trained on working in activities;
-He/She worked twenty-five years in housekeeping;
-He/She went to a sister facility to train for one day with activity staff member;
-He/She had not been enrolled in any training course for activity certification;
-He/She had been in position for one year.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said:
-Activity Director needed certifications;
-Facility had determined to invest in the Activity Director and purchased a course for him/her to participate in during September 2024;
-Activity Director was anticipated to complete coursework in October 2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the environment for three of 21 sampled residents (Resident #3, #67, and #89) was free from accident hazards when obse...
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Based on observation, interview, and record review, the facility failed to ensure the environment for three of 21 sampled residents (Resident #3, #67, and #89) was free from accident hazards when observations of the memory care unit showed residents had access to the unlocked clean utility room that contained three open electrical boxes, two tanks of oxygen, and cleaning supplies, and the unlocked biohazard room that contained sharps, as well as hazardous chemicals, and the unlocked area behind the nurses desk that contained a jug of drug destroyer and a bottle of multipurpose cleaner. The facility census was 104.
Review of the facility's Accidents and Supervision Policy, dated, 9/1/2021, showed in part:
-The resident's environment will remain free of accident hazards as is possible;
-Each resident will receive adequate supervision to prevent accidents;
-This includes
- Identifying hazards and risks;
- Evaluating and analyzing hazards and risks;
- Implementing interventions to reduce hazards and risks;
- Monitoring for effectiveness and modifying interventions when necessary.
-All staff are to be involved in observation and identifying potential hazards in the resident's environment;
-The facility should make reasonable efforts to identify the hazards and risk factors for each resident;
-Various sources provide information about hazards and risks in the resident environment;
- These sources may include:
- Environmental rounds;
- Individual observations.
1. Observation of the memory care unit on 9/16/24, at 9:23 A.M., showed:
- The clean utility room was unlocked;
- Three electrical boxes were open on the wall inside the unlocked clean utility room;
- A tank of oxygen sitting in a trolley;
- The gauge on the oxygen tank said the tank had 100% of oxygen in it;
- An empty tank of oxygen was sitting in the clean utility room in a trolley;
- Five cans of shaving cream were sitting on the sink in an unlocked clean utility room;
- A cup of clear liquid was sitting on the counter by the sink in the unlocked clean utility room;
- There was an orange stick sitting on the counter by the sink in the unlocked clean utility room;
- Trash was overflowing with used gloves and cigarette packages in the unlocked clean utility room;
- There was a black substance on the wall behind the trash can in the unlocked clean utility room.
Observation on 9/16/24, at 9:43 A.M. showed:
-The door to the clean utility was still unlocked:
-The Social Services Director (SSD) walked into the clean utility and came out with a pillow case;
-The SSD did not lock the door of the clean utility when he/she left the clean utility room;
-The area behind the nurses desk was unlocked;
-The area behind the nurses desk contained a bottle of multi-purpose cleaner, a bottle of perfume setting on the nurses desk and bottle of drug destroyer on the floor next to the shred box behind the nurses desk.
During an interview on 9/16/24, at 9:48 A.M., the SSD said:
-He/she did not know if the clean utility room should be locked or not;
-Residents should not have access to areas with unlocked electrical boxes or unsafe areas.
2. Review of Resident #3's care plan dated 8/6/24, showed:
-The resident has an Activities of Daily Living (ADLs) self care performance deficit;
-The resident has impaired cognitive function related to dementia;
-The resident resists cares.
Review of the Resident's PPS 5-Day Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated, 8/12/24, showed:
-Severe cognitive impairment;
-Physical and verbal behaviors directed towards others;
-Takes antipsychotics and antidepressants daily;
-Supervision with mobility using a wheelchair;
-Diagnoses included, dementia, anxiety, asthma, and stroke.
Observation on 9/16/24, at 9:50 A.M. showed:
-The resident propelling himself/herself in a wheelchair along the wall next to the unlocked clean utility room:
-The resident grabbed the door knob of the clean utility room door on his/her way by; (he/she was not able to turn the door knob);
-No staff were present on the hall;
-The clean utility door remained unlocked.
Observation on 9/16/24, at 9:58 A.M. showed:
-The door to the biohazard room unlocked;
-The biohazard room contained a bucket with black water and a mop setting in it;
-A tall cardboard box with multiple sharps containers full with sharps;
-A container of caulking compound open and sitting in the room;
-Certified Nurses Aide (CNA) D pushed two dirty linen barrels in to the biohazard room;
-CNA D closed the door and did not lock it.
Observation on 9/16/24 at 10:00 A.M. showed
-The biohazard door unlocked;
-The resident propelling himself/herself in a wheelchair by the unlocked biohazard door;
-There were no staff near the unlocked biohazard room or the unlocked clean utility room.
Observation 9/16/24 at 10:05 A.M. showed:
-10:05 A.M., CNA E and Licensed Practical Nurse (LPN) B walked into the unlocked clean utility room;
-10:35 A.M., CNA E and LPN B came out of the clean utility room and did not lock the door;
-10:42 A.M., CNA E and LPN B walked by the unlocked biohazard door;
-10:45 A.M., Neither CNA E or LPN B checked to see if the biohazard door was locked;
-10:55 A.M., CNA D took a trash barrel into the unlocked biohazard room;
-11:05 A.M., CNA D came out of the biohazard room and did not lock the door.
Observation 9/18/24 at 8:03 A.M. showed:
- The clean utility room unlocked;
- The clean utility room still contained the linen cart;
- Three electrical boxes were open on the wall inside the unlocked clean utility room;
- Five cans of shaving cream were sitting on the sink in unlocked utility room;
- A cup of clear liquid was sitting on the counter by the sink;
- There was an orange stick still sitting on the counter by the sink;
- Trash was overflowing with used gloves and cigarette packages;
- There was a still a black substance on the wall behind the trash can;
-The resident propelling himself/herself in a wheelchair up and down the hall along the walls next to the unlocked clean utility room and the unlocked biohazard room;
-There were no staff near the unlocked biohazard room or the unlocked clean utility room.
3. Review of Resident #89's care plan dated 2/22/24, showed:
-The resident has an ADL self care performance deficit;
-The resident has impaired cognitive function related to dementia;
-The resident resists cares.
Review of the resident's Significant Change MDS, dated , 8/9/24, showed:
-Severe cognitive impairment;
-Impairment on one side of upper and lower extremity;
-Uses a wheelchair for mobility with supervision;
-Diagnoses included, dementia, anxiety, and osteoporosis (a condition that causes bones to become weak and brittle).
Observation 9/16/24 at 10:10 A.M. showed:
-The resident came out of his/her room and pushed on the wall by the unlocked biohazard room door;
-The resident pushed on the unlocked biohazard door as he/she went up the hall;
-The door to the nurses station remained unlocked as the resident pushed along the wall next to the nurses station;
-No staff were present near the resident or the unlocked rooms or nurses station.
Observation 9/18/24 at 8:03 A.M. showed:
- The clean utility room unlocked;
- The clean utility room contained the linen cart;
- Three electrical boxes were open on the wall inside the unlocked clean utility room;
- Five cans of shaving cream were sitting on the sink in unlocked utility room;
- A cup of clear liquid was sitting on the counter by the sink;
- There was an orange stick sitting on the counter by the sink;
- Trash was overflowing with used gloves and cigarette packages;
- There was a still black substance on the wall behind the trash can;
-The resident propelling himself/herself in a wheelchair up and down the hall along the walls next to the unlocked clean utility room and the unlocked biohazard room;
-There were no staff near the unlocked biohazard room or the unlocked clean utility room.
4. Review of Resident #67's Annual MDS, dated , 8/9/24, showed:
-Moderate cognitive impairment;
-Impairment on one side upper extremity;
-Diagnoses included, dementia, anxiety, stroke and psychotic disorder( a disorder when people lose contact with reality).
Review of the resident's undated care plan showed:
-The resident is dependent on staff for meeting emotional, intellectual, physical and social needs;
-The resident has an ADL self-care performance deficit related to confusion from stoke;
-The resident has impaired cognitive function and impaired thought process related to dementia.
Observation on 9/17/24 at 10:15 A.M. showed:
- The clean utility room remained unlocked;
- The clean utility room still contained the linen cart;
- Three electrical boxes were still open on the wall inside the unlocked clean utility room;
- Five cans of shaving cream were still sitting on the sink in unlocked utility room;
- A cup of clear liquid was still sitting on the counter by the sink;
- There was an orange stick still sitting on the counter by the sink;
- Trash was still overflowing with used gloves, cigarette packages;
- There was a still black substance on the wall behind the trash can.
Observation on 9/17/24 at 10:19 A.M. showed:
-The resident walking up and down both sides of the by the unlocked clean utility room, and the unlocked biohazard room.
Observation 9/18/24 at 08:03 A.M. showed:
- The clean utility room unlocked;
- The clean utility room contained the linen cart;
- Three electrical boxes were open on the wall inside the unlocked clean utility room;
- Five cans of shaving cream were sitting on the sink in unlocked utility room;
- A cup of clear liquid was sitting on the counter by the sink;
- There was an orange stick sitting on the counter by the sink;
- Trash was overflowing with used gloves and cigarette packages;
- There was a still black substance on the wall behind the trash can;
-The resident walking up and down both sides of the by the unlocked clean utility room, and the unlocked biohazard room.
-There were no staff near the unlocked biohazard room or the unlocked clean utility room.
During an interview on 9/16/2024, at 10:12 A.M., CNA E said:
-This was his/her first day;
-He/she usually worked at a sister facility;
-He/she would expect the doors to the clean utility room, biohazard room, and nurses desk to be locked;
-The doors to the clean utility room and the biohazard room have been unlocked since he/she came in;
-Residents should not have access to sharps, dangerous chemicals, or any accident hazards.
During an interview on 9/23/2024, at 9:18 A.M., CNA D said:
-He/she was not sure if the doors to the clean utility room, biohazard room, and nurses desk should be locked;
-The doors to the clean utility room and the biohazard room have always been unlocked;
-Residents should not have access to sharps, dangerous chemicals, or any accident hazards.
During an interview on 9/23/2024, at 9:38 A.M., LPN B said:
-The lock broke on the nurse's station last night;
-The door to the nurse's station should be locked;
-He/she did not know if a work order had been filled out for the broken door;
-The doors to the clean utility and the biohazard room should be locked;
-Resident's should not have access to areas with sharps, open electrical boxes, or hazardous chemicals.
During an interview on 9/23/24 at 9:11 A.M., the Maintenance Director said:
-He/she tries to do a walk through every week and write on a list the things that need repaired;
-He/she would not expect the electrical boxes on the memory care unit to be accessible to the residents;
-He/she expects the door to the room containing the electrical boxes to be locked;
-He/she expects the door to the biohazard room to be locked;
-The nurses have keys to both of those rooms and they should be kept locked;
-The area behind the nurse's desk should be locked.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said:
-The door to the nurse's station should be locked;
-The doors to the clean utility and the biohazard room should be locked;
-Resident's should not have access to areas with sharps, open electrical boxes, or hazardous chemicals;
-He/she expects the nurses to ensure those rooms are not accessible to the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 residents had water at bedside that was easily ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had water at bedside that was easily accessible for four of 23 residents sampled (#90 #49, #87, and #12). The facility census was 104.
Review of the facility's undated policy for hydration showed, in part:
-The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health.
- Nursing staff shall assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols; the dietary manager or designee shall obtain the resident's beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay; the dietician will assess hydration as part of the comprehensive nutritional assessment within 72 hours of admission, annually, and upon significant change in condition.
-The assessment shall clarify the resident's current hydration status and individual risk factors for dehydration or fluid imbalance; the dietician shall use the data gathered from the nutritional assessment to the resident's fluid needs and whether intake is adequate to meet those needs.
-Interventions will be individualized to address the specific needs of the resident such as offering the resident a variety of fluids during and in between meals; provide assistance with drinking; ensure beverages are available and within reach; evaluate resident's medications that may place the resident at risk for dehydration; offer alternative fluids such as broths, popsicles, gelatin, and ice cream.
1. Review of Resident #90's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/19/2024 showed:
-Resident has minor cognitive impairment.
-Resident is dependent on a staff for eating.
-Resident needs partial/moderate assistance with oral hygiene.
-Diagnoses include stroke; high blood pressure; and paralysis of one side of the body.
Review of the resident's undated care plan showed:
-Resident has dehydration or potential fluid deficit related to poor intake.
-Resident has a swallowing problem. Resident at risk for impaired nutrition and dehydration due to dependence on tube feeding for all nutrition and hydration needs. All staff is to be informed of resident's special dietary and safety needs.
Review of the resident's active physician order sheet (POS), dated 9/18/24 showed:
-Regular diet, mechanical soft texture, nectar thick liquids consistency. Start date 7/10/24.
Review of progress notes dated 9/19/2024 2:22 PM showed:
-Resident was on antibiotics (ABT) for UTI (urinary tract infection) and has requested to not get out of bed thus far on this shift.
Review of progress notes dated 9/20/2024, unknown time, showed:
-Resident had ABT/UTI. Dependent on staff for cares; fluids encouraged.
Review of progress notes dated 9/22/2024, unknown time, showed:
-Continue ABT/UTI monitoring; fluids encouraged.
Observation and interview on 09/16/24 04:02 P.M. showed, the resident did not have water at bedside. The resident's daughter said when he/she asked for water, the staff brought flavored water, but the resident would prefer unflavored water.
Observation on 9/19/24 08:19 A.M., showed there was no water at bedside.
Observation on 09/19/24 11:54 A.M., showed there was no water at bedside.
Observation on 09/23/24 09:02 A.M., showed no thickened water.
During an interviews on 09/23/24 09:55 A.M., RN A said water is passed once in the morning and once in the afternoon before dinner.
During an interview on 09/23/24 10:16 A.M., CNA A said day shift passes water once during breakfast pass and once during lunch pass.
Observation on 09/23/24 11:15 A.M. showed no water being passed on Maple Hall between 9:00 A.M. and 11:15 A.M.
Observation and interview on 09/23/24 11:30 A.M. showed, RN A said the resident has a UTI. Observation showed the resident did not have water at bedside.
2. Review of Resident #12's, Quarterly MDS, dated [DATE], showed:
-He/She was cognitively impaired;
-He/She required supervised or touching assistance with eating;
-Diagnosis included lack of coordination, difficulty walking, muscle weakness, unsteadiness on feet, depression, and bipolar disorder (mental illness that causes extreme mood swings).
Review of the resident's care plan, revised 1/25/24, showed:
-He/She was at risk for dehydration and/or potential fluid deficit due to diuretic use (Lasix) and history of poor intake;
-Monitor and document intake and output as per facility policy;
-Monitor vital signs as ordered per protocol and record. Notify medical doctor of significant abnormalities;
-Monitor/document/report as needed any signs and symptoms of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness, or sitting/standing, increase pulse, headache, fatigue,/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes
-Notify Physician if: Persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours; abnormal lab. Date Initiated: 12/08/2023
-Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor and follow up as indicated.
-Offer and encourage adequate fluid as long as not contraindicated i.e.: signs of fluid overload.
Review of the physician's orders, dated 9/17/24, showed:
-Ordered 5/31/24, Regular diet, regular texture, regular/thin consistency.
During an interview on 9/16/24 at 10:27 A.M., the resident said:
-The facility did not pass water very often;
-He/She had no water in his/her room right now.
Observation on 9/18/24 at 8:00 A.M., showed the resident had no water in his/her room.
Observation on 9/18/24 at 8:16 A.M., showed the resident wheeled him/herself up the hallway next to the cooler and waited for staff to come by to have his/her water cup filled. No staff were observed in the area. The resident sat next to the cooler waiting for eight minutes. CNA A obtained ice for the resident when the resident said something to him/her.
3. Review of Resident #49's Quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had impairment on one side of upper and lower extremities;
-He/She required set up or clean up assistance with eating;
-Diagnoses included stroke (condition causing damage to the brain from an interruption of its blood supply), hemiplegia (condition causing weakness on one side of the body), heart failure, high blood pressure, diabetes (too much sugar in the blood), depression, post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, lack of coordination, pain in left shoulder, need for assistance with personal care, and osteoarthritis of the right shoulder (a chronic joint disease that causes the cartilage in one or more joints to break down over time).
Review of the resident's care plan, revised 7/30/24, showed:
-He/She had an ADL self-care performance deficit due to a stroke;
-He/She was able to feed him/herself but staff needed to set up his/her meals;
-Monitor and document any signs or symptoms of increased thirst and appetite;
-Ensure commonly used items (ice water) are within reach of resident prior to leaving room;
-He/She was on a diuretic medication due to edema.
Review of the physician's orders, dated 9/17/24, showed:
-Ordered 4/29/22, Regular diet, regular texture, regular/thin consistency.
During an interview on 9/16/24 at 6:22 P.M., the resident said:
-Water was passed only one time per day;
-He/She had never had his/her water cup changed out or washed.
Observation on 9/18/24 at 7:57 A.M., showed the water cup was half empty.
During an interview on 9/18/24 at 7:57 A.M., the resident said:
-He/She last received water and ice sometime yesterday afternoon.
Observation on 9/19/24 at 6:22 P.M., showed the resident had only 1/4 cup of water left in cup, no ice.
During an interview on 9/19/24 at 2:08 P.M., the resident said:
-He/She had not received ice or water pass yet today.
During an interview on 9/19/24 at 5:31 P.M., the resident said:
-Water was passed for the first time all day at 4:15 P.M.
Observation on 9/23/24 at 10:10 A.M., showed the resident was asleep. He/She had no water or ice in his/her cup.
4. Review of Resident #87's Quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had impairment on one side of upper extremity, and impairment on both sides of lower extremities;
-Diagnosis included traumatic spinal cord dysfunction, central cord syndrome as an after effect of disease, condition, or injury at the fifth cervical vertebra level of the cervical spinal cord (type of incomplete spinal cord injury characterized by weakness, loss of sensation below injury site, loss of bladder control, pain such as tingling and burning), paraplegia (paralysis of legs and lower body caused by spinal injury), spinal stenosis in cervical region (a chronic condition that occurs when spinal canal narrows, putting pressure on spinal cord and nerve roots), muscle weakness, and difficulty walking.
Review of the resident's care plan, revised 1/31/24, showed:
-He/She had diabetes mellitus;
-Observe for signs and symptom hyperglycemia including increased thirst;
-Ensure commonly used items (ice water) were within reach prior to leaving room;
-He/She had renal insufficiency due to kidney disease;
-He/She had potential for impairment of skin integrity;
-Resident will have no signs and symptoms of complications due to fluid deficit through the review date.
-The resident will have no signs and symptoms of complications related to fluid overload through the review date.
Review of the physician's orders, dated 9/17/24, showed:
-Ordered 1/25/24, Regular diet, regular texture, regular/thin consistence. Double portions every meal.
During an interview on 9/16/24 at 11:07 A.M., the resident said:
-It had taken the facility over a week to change out water;
-The facility did not pass ice or water everyday.
Observation on 9/16/24 at 11:15 A.M., showed no ice water had been passed.
Observation on 9/17/24 at 5:30 A.M., showed no ice water had been passed.
During an interview on 9/23/24 at 3:33 P.M., the Director of Nursing said ice and water should be passed two times per shift.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said:
-Ice water should be passed twice per each shift;
-Staff work 12 hour shifts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide trauma informed care to one sampled resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide trauma informed care to one sampled resident (Resident #49) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a traumatic event). The facility failed to mitigate triggers of loud noises that caused re-traumatization for one resident (Resident #49) who was residing on a hall with several residents who scream and yell out. The failed to identify and mitigate triggers for one resident (Resident #87) when the resident had identified several traumatic events. The facility also failed to identify and communicate interventions to staff for both residents to assist in promoting a sense of safety for both residents (Resident #49 and #87). The facility census was 104.
Review of facility policy, Trauma Informed Care, dated 9/1/22, showed:
-It is policy of facility to provide care and services which are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.
-The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which retraumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be addend to the residents care plan.
-The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understanding if interventions must be modified.
-In situations where a trauma survivor is reluctant to share their history, the facility will still try and identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.
1. Review of Resident #49 quarterly, minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/22/24, showed:
-He/She was cognitively intact;
-He/She had clear speech, and was able to make self-understood and understand others;
-He/She felt down, depressed or hopeless half or more days;
-He/She had impairment on one side of upper and lower extremities;
-He/She was dependent on walker and wheelchair;
-He/She was taking an antidepressant;
-His/Her mood severity score was a 12 (indicating moderate depression);
-He/She had trouble falling asleep or staying asleep or sleeping too much nearly every day;
-He/She felt tired or had little energy nearly every day;
-He/She exhibited a poor appetite or overeating on more than half of the days;
-He/She had trouble concentrating on things such as reading the newspaper or watching television on half or more of the days;
-Diagnoses included post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, and lack of coordination
Review of the resident's care plan, revised 3/15/24, showed:
-He/She had a history of a traumatic event;
-His/Her spouse was verbally and emotionally abusive to him/her with triggers of loud noises startling him/her;
-Known triggers of potential trauma included loud noises;
-No interventions identified for known triggers.
During an interview on 9/16/24 at 6:40 P.M., the resident said:
-His/Her ex-spouse choked him/her one time, went to jail, and was emotionally abusive;
-The resident across the hall was throwing a fit of yelling and cussing which triggered him/her;
-Loud noises trigger the resident to relive his/her abuse;
-The resident across the hall was yelling the other morning so the resident started yelling back at the other resident;
-Staff came and yelled at the resident for confronting the other resident.
Review of facility electronic medical record showed:
-On 5/1/22, resident had a trauma, abuse, neglect screening completed with a score of 4.0 which showed he/she had a history of abuse and/or neglect, increased vulnerability, psychiatric history and present mental health diagnosis, and had depressive illness including low self esteem, isolation, and withdrawn behaviors. His/Her spouse had physically and emotionally abused him/her.
-On 1/1/23, the resident had a trauma informed care assessment completed and no trauma was noted;
-On 11/8/23, the resident had a trauma informed care assessment completed and no trauma was noted;
-On 4/22/24, the resident had a trauma informed care assessment completed and reported that his/her ex husband was verbally and emotionally abusive.
-On 7/23/24, the resident had a trauma informed care assessment completed and reported that his/her ex husband was verbally and emotionally abusive;
During an interview on 9/18/24 at 3:28 P.M., Certified Nurse Aide (CNA) A said he/she did not know this resident was triggered by hearing yelling.
During an interview on 9/23/24 at 9:43 A.M., Certified Medication Technician (CMT) A said he/she was not aware of the resident having any triggers.
During an interview on 9/23/24 at 10:05 A.M., Registered Nurse (RN) A said he/she was not aware of the resident having any trauma triggers.
During an interview on 9/18/24 3:40 P.M., the Social Services Director said:
-He/She was aware this resident was triggered by loud noises;
-He/She was not aware the resident was triggered by other residents yelling on the hall, but was aware the resident's roommate would get upset and come out yelling at other residents across the hall;
-The resident has a history of closing his/her door a lot, and likes to do arts and crafts as part of his/her coping strategies;
-He/She communicates the resident's triggers directly with the charge nurse on the hall who then verbally communicates with the staff providing direct care.
2. Review of Resident #87's quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had clear speech, was able to make self-understood, and understand others;
-He/She had impairment on one side of upper extremity, and impairment on both sides of lower extremities;
-He/She was dependent on a wheelchair;
-Behaviors included hallucinations and delusions;
-He/She had an an antipsychotic on routine basis;
-Diagnosis included central cord syndrome as a after affect at the cervical vertebra five level of the cervical spinal cord (type of incomplete spinal cord injury characterized by weakness, loss of sensation below injury site, loss of bladder control, pain such as tingling and burning), dementia (loss of cognitive function such as thinking, remembering, and reasoning), paraplegia (paralysis of legs and lower body caused by spinal injury), cognitive communication deficit, muscle weakness, and difficulty walking.
Review of the resident's care plan, revised 8/9/24, directed staff of the following:
-Resident had past trauma of being in a tornado, car accident that left him/her with a spinal cord injury, being jumped (assaulted or attacked), and homeless. Resident reported no triggers or distress related to traumas;
-He/She had impaired cognitive function/dementia and impaired thought processes;
-He/She stated on 1/26/24 that everyone was out to get him/her and he/she was tired of the witches in the place. He/She stated he knew for a fact that a CNA was casting spells with chicken bones and the constant laughter in the hallway and was always smiling about him/her;
-He/She stated on 3/13/24 that therapy staff were making fun of him/her, and he/she knew people were making fun of him/her;
-He/She stated on 6/5/24 that he/she knew when people were making fun of him/her and then refused his/her morning shower stating shower aide was a witch and that his/her potions and lotions cause him/her to burn and itch;
-The care plan did not identify any resident triggers for prior trauma.
Observation on 9/17/24 at 10:49 A.M., showed the resident came out of his/her room yelling at Resident #87 sitting in a wheelchair in the hallway.
During an interview on 9/17/24 at 10:55 A.M., CNA A said:
-The resident had specific behaviors targeting him/her and RN A;
-The resident will state that he/she put stuff in the resident's soap to make him/her itch.
During an interview on 9/23/24 at 9:43 A.M., CMT A said:
-The resident was triggered by certain staff on the hall, specifically CNA A and RN A;
-The resident gets agitated at others and call staff witches and a cuss word;
-The resident will only accept his/her medication and treatments from CMT A, because he/she did not have a problem with him/her and he/she liked to interact with CMT A.
During an interview on 9/23/24 at 10:05 A.M., RN A said:
-The resident was very delusional and paranoid;
-The resident acts out every Friday afternoon;
-He/she was aware the resident was best supported by staff praying with him/her as long as the person praying with him/her was not the person he/she was targeting;
-He/she had learned the resident was best supported when the staff member he/she is targeting walks away. He/she had learned the more that staff members interact with the resident, the likelihood the resident will continue to escalate.
During an interview on 9/18/24 at 3:40 P.M., the Social Services Director said:
-The resident was triggered by any kind of mention of mental health around him/her;
-The resident could be a difficult resident to identify his/her triggers, as he/she could be triggered by someone simply approaching him/her and feeling threatened and having severe paranoia;
-The resident would start calling people witches and warlocks when he/she was triggered;
-The resident seemed to be triggered very easily.
3. Review of facility training logs for last year showed no trauma informed care training was provided to the facility staff.
During an interview on 9/18/24 at 3:14 P.M., the MDS Coordinator said the social services director completed the trauma informed care section regarding care plans and the trauma informed care assessments.
During an interview on 9/18/24 at 3:28 P.M., CNA A said:
-He/She had not received any trauma informed care training;
-He/She was not aware of any residents that were triggered from their past abusive relationship;
-No one had conveyed any resident trauma triggers to him/her or methods of interventions;
-He/She did know that some residents are triggered by yelling.
During an interview on 9/23/24 at 9:43 A.M., CMT A said:
-He/she received trauma informed care training a long time ago, but no training in the past year;
-If he/she observed a resident was being triggered by another resident's yelling he/she would separate the residents and inform the nurse.
During an interview on 9/23/24 at 10:05 A.M., RN A said:
-He/she had no trauma informed care training by the facility since starting three months ago;
-He/she was not aware of trauma triggers for residents.
During an interview on 9/18/24 3:40 P.M., the Social Services Director said:
-He/She completed trauma assessments upon admission, every quarter, and annually;
-He/She notified staff of trauma triggers directly by going to the charge nurse;
-The charge nurse then filtered down the information to floor staff;
-He/She was not aware of any trauma informed care training to staff at facility since he/she started the position in February;
-If a resident was triggered due to a past abusive relationship/marriage by another resident who was yelling and cussing loudly then he/she would offer to look at moving the resident to create a calming environment, work to help resident identify and develop coping skills, and obtain noise canceling headphones;
-The facility had purchased noise canceling headphones in the past for residents who were triggered by loud noises but not for Resident #49.
During an interview on 9/23/24 at 3:33 P. M, the Administrator said:
-He/She completed trauma informed training to staff in facility;
-He/She trained on trauma two or three times;
-He/She documented training in staff meeting notes.
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 F0725
(Tag F0725)
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 sufficient nursing staff to meet basic care n...
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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 sufficient nursing staff to meet basic care needs for seven residents (Residents #13, #67, #80, #12, #49, #87, and #74) including assistance to reposition and incontinent care for two residents (Resident #13 and #80), failed to provide basic hygiene for one resident (Resident #67), and failed to provide assistance with bathing for three residents (Residents #12, #49 and #87) of 21 sampled residents. Additionally the facility failed to answer call lights timely for nine of 20 Resident Council attendees. The facility census was 104.
Review of the facility provided policy Activities of Daily Living (ADLs: tasks completed in a day to care for oneself) dated 9/1/21 showed:
-A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.
Review of the facility provided policy Bathing a Resident dated 9/1/21 showed:
-It is the practice of this facility to assist residents with bathing to maintain proper hygiene.
Review of the facility provided policy Nursing Services and Sufficient staff dated 9/1/21 showed:
-It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment;
-The facility will supply services by sufficient numbers of each of the following personnel types on a 24 hour basis to provide nursing care to all residents in accordance with resident care plans;
-Providing care includes, but not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.
1. Review of Resident #13's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated, 6/20/24, showed:
-Severe cognitive impairment;
-Dependent on staff for Activities of ADLs;
-Incontinent of bowel and bladder;
-Diagnoses included, dementia, high blood pressure and anxiety.
Review of the resident's care plan revised, 3/27/24, showed:
-The resident has an ADL self care performance deficit;
-The resident is dependent on staff for toileting;
-Clean peri-area after each incontinent episode;
-The resident has the potential for pressure ulcer development related to incontinence;
-The resident requires total assistance of one staff for transfers;
-The resident has the right to be treated with dignity.
Continuous observation of the resident beginning on 09/16/24 at 09:20 A.M., showed:
-09:20 A.M., the resident was setting at the table in the dining room in his/her wheelchair;
-10:13 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident;
-10:59 A.M., the resident still setting in his/her wheelchair at the table with his/her eyes closed;
-11:03 A.M., the resident still setting in his/her wheelchair at the table and LPN B walked by and did not provide incontinent care for the resident;
-11:25 A.M., CNA D walked by the resident setting in his/her wheelchair at the table and did not offer to provide incontinent care for the resident;
-12:26 P.M., lunch was delivered to the memory care unit and was still setting in his/her wheelchair at the table with his/her eyes closed;
-12:42 P.M., lunch was delivered to the resident and he/she was still at the table in his/her wheelchair;
-12:46 P.M., no staff have repositioned or toileted the resident;
- 01:01 P.M., the resident finished his/her lunch and was still setting in his/her wheelchair at the table and no staff have provided incontinent care for the resident;
-01:25 P.M., the resident was setting at the table in his/her wheelchair and no staff have toileted the resident.
Continuous observation of the resident beginning on 09/17/24 at 05:39 A.M., showed:
-05:39 A.M., the resident was setting at the table in the dining room in his/her wheelchair;
-06:15 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident;
-07:30 A.M., the resident was still setting in his/her wheelchair at the table;
-08:30 A.M., the resident was setting at the table in the dining room in his/her wheelchair;
-09:30 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident.
2. Review of Resident #67's Annual MDS dated , 7/17/24, showed:
-Moderate cognitive impairment;
-Visual impairment;
-Substantial assistance from staff for toileting;
-Supervision of staff for dressing;
-Incontinent of urine;
-Diagnoses included, stroke, depression, high blood pressure and cataracts (a clouding of the eye's lens that can lead to vision loss).
Review of resident's undated care plan showed:
-The resident has an ADL self care performance deficit;
-The resident requires supervision for dressing;
-The resident requires supervision with personal hygiene;
-The resident requires assistance with toileting;
-The resident has the right to be treated with dignity.
Observation on 09/16/24 at 09:50 A.M., showed:
-The resident walking into the dining room;
-The resident hair was unkempt and his/her glasses had white specks on the lenses;
-The resident's pants and shirt had black stains on them.
Observation on 09/16/24 at 12:24 P.M., showed:
-The resident was setting in the dining room at a table;
- The resident's glasses still had white specks on the lenses;
-The resident's hair was still unkempt and his/her clothes still had black stains on them.
Observation on 09/17/24 at 08:01 A.M., showed:
-The resident was setting in the dining room;
-The resident was wearing the same clothes as yesterday;
-The resident's pants and shirt still had black stains on them.
-The resident's hair was unkempt and his/her glasses still had white specks on the lenses.
3. Review of Resident #80's Quarterly MDS dated [DATE], showed:
-Severe cognitive impairment;
-Dependent on staff for ADLs;
-Incontinent of bowel and bladder;
-Diagnoses included, dementia, high blood pressure and anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues).
Review of the resident's care plan revised, 6/13/24, showed:
-The resident has an ADL self care performance deficit;
-The resident requires total assistance of one to two staff for showers and toileting;
-The resident requires total assistance of one to two staff for transfers;
-The resident has impaired cognitive function related to dementia;
-The resident has the right to be treated with dignity;
-The resident has the right to privacy and confidentiality.
Continuous observation of the resident beginning on 09/16/24 at 09:20 A.M., showed:
-09:20 A.M., the resident was setting at the table in the dining room in his/her wheelchair;
-10:13 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident;
-10:59 A.M., the resident was still setting in his/her wheelchair at the table with his/her eyes closed;
-11:03 A.M., the resident was still setting in his/her wheelchair at the table and LPN B walked by and did not provide incontinent care for the resident;
-11:25 A.M., CNA D walked by the resident setting in his/her wheelchair at the table and did not offer to provide incontinent care for the resident;
-12:26 P.M., lunch was delivered to the memory care unit and the resident was still setting in his/her wheelchair at the table with his/her eyes closed;
-12:42 P.M., lunch was delivered to the resident and he/she was still at the table in his/her wheelchair;
-12:46 P.M., no staff have repositioned or toileted the resident;
- 01:01 P.M., the resident finished his/her lunch and was still setting in his/her wheelchair at the table and no staff have provided incontinent care for the resident;
-01:25 P.M., the resident was setting at the table in his/her wheelchair with his/her eyes closed and no staff have toileted the resident.
Continuous observation of the resident beginning on 09/17/24 at 05:39 A.M., showed:
-05:39 A.M., the resident was setting at the table in the dining room in his/her wheelchair;
-06:15 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident;
-07:30 A.M., the resident was still setting in his/her wheelchair at the table and the DON delivered breakfast to him/her and the DON did not offer to reposition or toilet the resident;
-08:30 A.M., the resident was setting at the table in the dining room in his/her wheelchair;
-09:30 A.M., LPN B said good morning to the resident and did not toilet the resident.
During an interview on 9/18/24 at 1:14 P.M., CNA D said:
-He/she tries to toilet Residents #13, #67 and # 80 at least every two hours, but he/she did not have enough time today;
-It gets busy sometimes and he/she does not have time;
-Incontinent residents should be toileted at least every two hours.
During an interview on 9/18/24 at 1:28 P.M., LPN B said:
-The CNAs usually toilet the residents;
-He/she expects the residents to have incontinent care every two hours or as needed;
-He/she was not aware the incontinent residents had not been toileted for over two hours;
-Incontinent residents should be toileted at least every two hours.
During an interview on 9/18/24 at 1:42 P.M., the DON said
-He/she expects residents to have incontinent care every two hours or as needed;
-He/she was not aware the incontinent residents had not been toileted for over two hours;
-He/she expects incontinent residents should be given pericare and changed at least every two hours.
4. Review of Resident #12's Quarterly MDS) dated [DATE], showed:
-He/She was cognitively impaired;
-He/She had moderate difficulty with hearing, speaker has to increase volume and speak distinctly;
-He/She had clear speech and was able to make self understood and understand others;
-He/She had no impairment to upper or lower extremities;
-He/She was dependent on a walker/wheelchair;
-He/She required supervised or touching assistance with bathing, sit to stand and chair to bed transfers;
-Diagnosis included lack of coordination, difficulty walking, muscle weakness, unsteadiness on feet, depression, bipolar disorder (mental illness that causes extreme mood swings).
Review of the resident's care plan, revised 9/1/24, showed:
-He/She had an ADL self-care performance deficit due to stroke and chronic obstructive pulmonary disease (COPD);
-Resident required assistance from one staff with showering twice weekly and as necessary;
-Check nail length and trim and clean on bath day and as necessary;
Observation on 9/16/24 at 10:06 A.M. showed:
-The resident's hair was greasy and had not been brushed;
-He/She had long nails with black/brown color underneath his/her nail bed.
During an interview on 9/16/24 at 10:06 A.M., Resident #12 said:
-He/She did not get showers or baths when he/she wanted them;
-He/She had went 7-8 days without a shower;
-He/She wanted a shower twice a week on Mondays and Fridays;
-He/She had scheduled shower days, but he/she never got showers on his/her scheduled shower days;
-He/She was lucky because he/she got one shower on Saturday during the past week;
-During the night he/she could not find staff;
-Call lights are on throughout the night and there was no staff to answer the lights;
-Food was not served on time;
-Staff do not pass ice water very often, he/she had to go after water themselves.
Review of shower schedule, dated 4/30/24, in the shower book for Maple hall showed:
-His/Her room number had shower days on Mondays and Thursdays.
Review of Resident #12's shower sheets, dated 6/1/24 to 9/17/24 , showed:
-He/She received one shower in September on 9/17 out of [NAME] scheduled opportunities, which was nineteen days from his/her last prior shower in August;
-He/She received five showers in August on 8/1, 8/7, 8/13, 8/26, and 8/29 of nine schedule opportunities;
-He/She received four showers in July on 7/2, 7/9, 7/19, and 7/23 of nine scheduled opportunities;
-He/She received three showers in June on 6/17, 6/20, and 6/26 of eight scheduled opportunities.
5. Review of Resident #49's Quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had clear speech, and was able to make self-understood and understand others;
-He/She felt down, depressed or hopeless half or more days;
-He/She had no behavioral symptoms or rejection of care;
-He/She had impairment on one side of upper and lower extremities;
-He/She was dependent on walker and wheelchair;
-He/She required substantial/maximal assistance with bathing;
-He/She was frequently incontinent;
-Diagnoses included: stroke (condition causing damage to the brain from an interruption of its blood supply), hemiplegia (condition causing weakness on one side of the body), heart failure, high blood pressure, diabetes (too much sugar in the blood), depression, post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, lack of coordination, pain in left shoulder, need for assistance with personal care, osteoarthritis of the right shoulder (a chronic joint disease that causes the cartilage in one or more joints to break down over time).
Review of the resident's care plan, revised 7/30/24, showed:
-He/She had an ADL self-care performance deficit due to hemiplegia;
-He/She required extensive assistance with one person assist for shower twice weekly and as necessary;
-He/She required assistance washing under his/her arm, abdominal folds, and lower body;
-He/She had a rash under breast and pannus due to moisture;
-Preventive skin care as ordered, keep area under breast and pannus clean and dry.
During an interview on 9/16/24 at 6:24 P.M., Resident #49 said:
-Showers were very infrequent;
-The last shower he/she had was less than a week ago and the shower prior to that was about 2 weeks in between showers;
-Not having showers regularly made him/her feel dirty and disgusting;
-Prior to his/her stroke he/she was taking two or three showers a day;
-He/She would like to receive at minimum of two showers a week;
-He/She was scheduled to have showers on Tuesdays and Fridays, but he/she rarely received showers as scheduled;
-A lot of times there was not any pads or sheets available;
-Staff do not keep beds made as there was not enough sheets to put back on the beds;
-He/She had to sleep on a bare mattress due to facility not having any clean sheets;
-Water is only passed one time a day;
-The facility had never changed out his/her water cup since he/she had been there;
-Call light response time is slow;
-He/She had to wait thirty minutes or more for his/her call light to be answered.
Review of shower schedule, dated 4/30/24, in shower book on Maple hall showed:
-His/Her room number was assigned shower days on Mondays and Thursdays.
Review of shower sheets, dated 6/1/24 to 9/17/24 , showed:
-He/She received one shower in September on 9/5 out of five scheduled opportunities;
-He/She received two showers in August on 8/6 and 8/21 out of nine scheduled opportunities;
-He/She received two showers in July on 7/9 and 7/21 out of nine scheduled opportunities;
-He/She received two showers in June on 6/15 and 6/25 out of eight scheduled opportunities;
-He/She received only 7 out of 31 shower opportunities from June to September.
6. Review of Resident #87's Quarterly MDS, dated [DATE], showed:
-He/She was cognitively intact;
-He/She had clear speech, was able to make self-understood, and understand others;
-He/She had impairment on one side of upper extremity, and impairment on both sides of lower extremities;
-He/She was dependent on a wheelchair;
-He/She was dependent for bathing and tub transfers;
-Diagnosis included traumatic spinal cord dysfunction, central cord syndrome as an after effect of disease, condition, or injury at the fifth cervical vertebra level of the cervical spinal cord (type of incomplete spinal cord injury characterized by weakness, loss of sensation below injury site, loss of bladder control, pain such as tingling and burning), paraplegia (paralysis of legs and lower body caused by spinal injury), spinal stenosis in cervical region (a chronic condition that occurs when spinal canal narrows, putting pressure on spinal cord and nerve roots), muscle weakness, and difficulty walking.
Review of the resident's care plan, revised 1/31/24, showed:
-Resident had an ADL self-care performance deficit;
-He/She was dependent on two staff for transfers from chair to bed, and shower;
-He/She required set up, supervision, and physical assistance to maintain personal hygiene;
-Revision 7/5/24 showed patient refused shower that morning because he/she said shower aide was a witch and that his/her potions and lotions cause him/her to burn and itch.
During an interview on 9/16/24 at 10:40 A.M., Resident #87 said:
-He/She received a shower one time every two weeks;
-He/She felt like garbage when he/she had to go so long without showers;
-He/She had a shower on 9/14, prior to that his/her last shower was two weeks prior;
-He/She would like to have a shower every day;
-His/Her bedding is only changed every two weeks;
-Water is not passed to his/her room everyday.
Review of shower schedule, dated 4/30/24, in shower book for Maple hall showed:
-His/Her room number was assigned shower days on Wednesdays and Saturdays.
Review of shower sheets, dated 6/1/24 to 9/17/24 , showed:
-He/She had no documented showers in September out of four opportunities, and he/she had one documented refusal on 9/17/24;
-He/She received three showers in August on 8/7, 8/17, and 8/31 out of nine scheduled opportunities, with no documented refusals;
-He/She received two showers in July on 7/3 and 7/7 out of nine opportunities with 2 refusals on 7/19 and 7/24;
-He/She received three showers in June on 6/5, 6/19, and 6/26 out of nine scheduled opportunities, no documented refusals;
-He/She received 8 out of 31 opportunities for showers, and 3 refusals out of 31 scheduled opportunities for showers.
During an interview on 9/16/24 at 12:11 P.M., Certified Nurse Aide (CNA) A said:
-He/She was only aide scheduled to work Maple hall most of the time;
-He/She was a shower aide, but he/she was pulled from completing showers to work the floor all the time;
-Residents go without showers for much longer than a week at time due to staffing shortages;
-He/She had given showers and the white towels will be black;
-He/She did not have time to do all patient care needs due to staffing;
-He/She had three residents on Maple hall that required feeding assistance and there was insufficient staff to feed the residents in timely manner;
-Laundry staff do not stock linens;
-He/She had to go to laundry to obtain linens because linens were not restocked on halls.
During an interview on 9/16/24 at 7:48 P.M., Certified Medication Technician (CMT) A said:
-Insufficient staff working the facility was an issue that affected patient care;
-He/She had to work late because he/she had to help the CNAs work the floor and had to stop passing medications;
-He/She had to stop medication passes to assist with passing food trays on the floor;
-Showers were not getting done;
-The hall had only one CNA scheduled, but needed two to meet resident cares due to transfers, incontinence, and Hoyers;
-Staffing is an issue which has resulted in patient care not getting done;
-Showers were not being completed due to staffing shortages;
-The shower aide was constantly pulled to floor to work as a CNA so showers were not getting completed.
During an interview on 9/17/24 at 5:18 A.M., Licensed Practical Nurse (LPN) A said:
-Biggest issue in the facility was staffing;
-He/She had been asked to cover multiple halls due to staffing shortages;
-He/She was not comfortable covering multiple halls due to residents with tracheotomies that needed to be checked more frequently;
-He/She found that it was hard to hold CNAs accountable when that CNA was the only CNA working the floor;
-Patient care needs were not being met with just one aide covering a hall.
During an interview on 9/17/24 at 5:48 A.M., CNA B said:
-Staffing was an issue in facility;
-Residents did not receive adequate pericare, toileting, transfers, feeding assistance, and showers as a result of staffing shortages;
-There had been shortage of bed pads and sheets;
-Laundry staff was short for time period;
-He/She had to go to other halls to track down bed pads and sheets;
-Facility has ran out of sheets and bed pads.
During an interview on 9/23/24 at 10:05 A.M., Registered Nurse (RN) A said:
-There was never enough staff;
-Staff do the best they can to meet resident needs but there was never enough staff to go around;
-Resident care suffered as a result of short staffing;
-One CNA was assigned thirty residents and half of the residents on the hall were incontinent;
-The CNA was also expected to pass drinks and meal trays;
-The CMT had to stop passing medications and assist at meal times;
-Showers are a problem throughout the facility, not just on one hall;
-Showers are not done due to not having sufficient staff.
During an interview on 9/23/24 at 3:33 P.M., the Director of Nursing said:
-The facility was doing the best it could with staffing;
-He/She could not control staff call ins.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said:
-Showers had not been completed twice weekly due to staffing;
-His/Her goal was to have two CNAs, a CMT, and a nurse working on each hall;
-Time goal had not been met due to staffing in facility.
7. During a group interview of the Resident Council on 9/18/24 at 10:00 A.M., eight of 20 residents (Residents #13, #67, #80, #12, #49, #87, #74, and #12) said:
-Call times take a long time and can be an hour or longer;
-Delays for call lights to be answered is due to the staff being overworked and short-handed;
-At night there is not enough staff to take care of the residents;
-On the weekends staffing is very low.
8. Review of Resident #74's admission assessment, completed by facility staff, dated 9/10/24, showed:
-He/She was cognitively intact;
-Incontinent of both bowel and bladder;
-Diagnoses included brain disease; shortness of breath; urinary tract infection; kidney disease; asthma; heart disease; depression; osteoarthritis; malnutrition.
Review of the resident's undated care plan, showed:
-Resident's autonomy and dignity will be honored in the personal choices they make;
-Resident had an ADL performance deficit;
-Resident was at risk for falls.
Review of progress notes dated 9/14 showed:
-Resident continued ABT (antibiotic therapy) for UTI (urinary tract infection) with no adverse reactions. Fluids encouraged while awake.
Review of progress notes dated 9/15 showed:
-Resident remained on ABT/UTI without any adverse reaction.
Review of Progress notes dated 9/16 showed:
-Resident continued ABT/UTI with no adverse reaction. Resident was incontinent with some control. Assist of one with toileting and cares. Fluids encouraged while awake.
Review of progress notes, dated 9/17, showed:
-Continued Cipro (antibiotic) for UTI; encouraged to increase water intake.
Observation and interview on 09/16/24 09:59 A.M. showed:
-The resident was observed sitting on bed in a hospital gown. The resident said he/she had been waiting since 8:30 A.M. and expressed frustration that he/she was not dressed yet.
-The resident said he/she often doesn't get help to the bathroom in time and sometimes soils themselves while waiting for assistance.
During an interview on 09/17/24 at 11:19 A.M., the resident's daughter said:
-She is concerned the resident has not had a bath since he/she has been here (admit date : [DATE]) and said the resident has started scratching at his/her head due to his/her hair and scalp being dirty.
Observation and interview on 09/23/24 at 09:13 A.M., showed:
-The resident was unshaven and resident said he/she asked several days ago for assistance. He/she said there is not enough staff at the facility to help resident shave.
During an interview on 09/18/24 at 03:35 P.M., Nurse B said:
-The resident's shaving/shower schedule depends on resident preference vs. resident schedule and there are residents that are scheduled for twice a week.
During an interview on 09/19/24 at 07:08 A.M., CNA B said:
-He/she checks on the resident to see if he/she needs to use the bathroom and the resident uses a urinal.
During an interview on 09/23/24 at 10:16 AM , CNA A said:
-There is not enough staff in general, but especially the CNAs. It makes employees and residents on edge because residents do not get changed or put down for a nap in a timely manner.
-He/she is working alone on the floor on average, 3-4 times per week and does not always get breaks.
During an interview on 09/23/24 at 03:36 PM, the Administrator said:
-Most of the time the facility has enough staff to meet the residents needs. The goal is to have two CNAs per hall, but it does not always happen due to staff calls out.
MO#241353
MO#241172
MO#241807
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** 2. Review of Resident #12'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 #12's, quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/6/24, showed:
-He/She was cognitively impaired.
-He/She had clear speech and was able to make self understood and understand others;
-He/She had no impairment to upper or lower extremities;
Diagnosis included breathing abnormality, asthma (a lung disease that affects the airways, making it difficult to breathe), cognitive communication deficit (difficulty with communication that's caused by disruption in cognitive processes such as attention, memory, or problem solving, emphysema (a lung condition that causes shortness of breath), chronic obstructive pulmonary disease (a lung disease that makes it difficult to breath).
Review of the resident's care plan, revised 9/1/24, dated:
-He/She had emphysema, chronic obstructive pulmonary disorder due to smoking;
-Give aerosol or bronchodialator as ordered. Monitor/document any side effects and effectiveness;
-Head of bed elevated to or out of bed upright in a chair;
-Monitor for difficulty breathing (dyspnea) or exertion. Remind resident not to push beyond endurance;
-Monitor for signs and symptoms of impending asthma attack: coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing, shortness of breath, tightness of neck or chest muscles, malaise or fatigue;
-Monitor for anxiety. Offer support, encourage resident to vent frustrations, fears. Reassurance. Give as needed medications for anxiety as ordered.
-Monitor/document/report as needed any signs and symptoms of respiratory infection.
-Occupational therapy consult for energy conservation recommendations.
Review of the physician's orders, dated 9/17/24, showed:
-Order started 5/16/23, Preventil HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate), 2 puffs inhale orally every 4 hours as needed for shortness of breath related to chronic obstructive pulmonary disease, unspecified , emphysema, unspecified, shortness of breath or wheezing;
-No orders to self administer medications.
Review of the electronic medical record showed:
-No self-administration of medications assessment completed.
Observation on 9/16/24 at 10:06 A.M., showed an albuterol sulfate inhaler on the bedside table beside the resident's bed. The inhaler showed 50 on the side of inhaler dispenser.
Observation on 9/19/24 at 5:24 P.M., showed two inhalers laying on the bedside table in the resident's room. The ventolin inhaler at bedside with 000 showing in dispenser and albuterol sulfate inhaler with no visible number on the inhaler unit.
Observation on 9/23/24 at 9:54 A.M., showed an albuterol inhaler labeled and dated as filled on 9/19/24. Number displaying on inhaler showed 180/16.
During an interview on 9/23/24 at 9:43 A.M., Certified Medication Technician (CMT) A said:
-He/She was not sure if resident was allowed to keep his/her inhaler at bedside;
-The inhaler is administered by the nurse;
-The other nurse kept the inhaler in his/her medication cart.
During an interview on 9/23/24 11:19 A.M., Registered Nurse A said:
-He/She had only one resident on the Maple hall that self administered medications;
-Resident #12 was not able to self administer his/her medications;
-Resident #12 should not have his/her inhaler at bedside;
-Residents must have physician's orders and self-administration of medications assessment completed prior to being able to self-administer medications.
During an interview on 9/23/24 at 3:33 P.M., the DON said residents who have medications at bedside should have a physician's order and self-administration of medication assessment.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said:
-Residents who self-administer medications should have physician's orders;
-Residents who self-administer medications should have a self-administration of medication assessment completed.
3. Observation on 9/16/24 at 9:08 A.M., showed the medication cart on the [NAME] hall was unlocked and unattended. The treatment cart on the Maple hall was unlocked and unattended.
Observation on 9/16/24 at 9:33 A.M., showed the treatment cart on the Maple hallway was unlocked and unattended.
Observation on 9/16/24 at 7:39 P.M., showed the medication cart on the [NAME] hall was unlocked and unattended in hallway outside of rooms B18 and B19. Staff was not in line of sight of the cart. Drawers to the cart were facing the middle of the hall.
Observation on 9/16/24 at 7:46 P.M., showed the treatment cart was unlocked on the Maple hall.
Observation on 9/17/24 at 5:06 A.M., showed the medication cart on the Maple hall was left unlocked and unattended. Licensed Practical Nurse (LPN) A was observed coming out of room A-25 at the end of the hall while the medication cart was up at the nurses station.
Observation on 9/23/24 at 8:57 A.M., showed the treatment cart was unlocked on the Maple Hall.
Observation on 09/23/24 08:57 AM, showed the treatment cart unlocked on the Maple hall.
During an interview on 9/23/24 at 9:43 A.M., CMT A said:
-Medication carts should be locked all the time;
-He/She has observed residents come by the medication cart and grab at things on the medication cart;
-The medication treatment cart should be locked, but staff sometimes forget.
During an interview on 9/23/24 11:19 A.M., RN A said:
-Medication carts should be locked at all times.
-Medication and treatment carts should not be left unattended and unlocked.
During an interview on 9/23/24 at 3:33 P.M., the DON said medication carts should be locked when not attended.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said medication carts should be locked when staff are not present.
Based on observation, interview and record review, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for five (Resident #12,#15, #69, #77 and #154 ) out of 23 sampled residents when the facility failed to store medications in a locked storage area for Resident #12 and Resident #154 and failed to ensure medications were inaccessible to unauthorized staff and residents when the medication cart was left unlocked and unattended. Additionally, the facility failed to ensure staff were able to read the pharmacy label for Resident #69, failed to destroy expired medications for Resident #69 and Resident #77, and failed to destroy expired house stock medications. The facility census was 104.
Review of the facility's Medication Storage Policy, revised, 9/1/21, showed in part:
- It is the policy of this facility to ensure all medications will be stored according to the manufacturers recommendation and securely;
- All drugs and biologicals will be stored in locked medication rooms or carts;
- Only authorized personnel will have access to medications;
- Medication that is outdated, discontinued or with missing or illegible labels will be destroyed.
1. Observation on 09/18/24, at 11:58 P.M., of the medication cart showed:
-The second, third and fourth drawers of the medication cart had multiple loose pills, dirt and debris in the bottom of the drawer;
- The fourth drawer had a white liquid spilled in the bottom of the drawer;
- A bottle of house stock Milk of Magnesia (used to treat constipation) with an expiration date of April 2024;
- A bottle of Flonase Nose Spray (used to treat allergies) for Resident #15 with an expiration date of July 2024;
- A bottle of Haldol (used to treat certain types of mental disorders) for Resident #77 with an expiration date of July 2024;
- A bottle of Valproic Acid (used treat seizures and bipolar disorder) for Resident #69 with the label covered with sticky liquid and illegible.
During an interview on 9/18/14, at 12:08 P.M., Certified Medication Technician (CMT) B said:
-Expired medications should be removed from the medication cart daily;
-The CMTs are responsible for making sure the expired medications are taken out of the medication cart;
-He/she was not sure who was responsible for making sure the there were no loose pills in the bottom of the medication cart and that the medication cart was clean;
-There should not be loose pills, dirt and debris in the bottom of the medication cart;
-Any labels that are damaged or unreadable should be replaced;
-The nurses get replacement labels for medications if needed;
-The nurse takes care of destroying expired medications.
During an interview on 09/18/24, at 12:16 P.M., Licensed Practical Nurse (LPN) B said:
-Expired medications should be removed from the medication cart at least every week;
-The CMTs are responsible for removing the expired medications from the medication cart;
-The nurses should ensure the expired medications are removed from the medication cart by the CMTs and that the cart is clean and good order;
-He/she does not have time to ensure this gets done;
-There should not be loose pills, dirt and debris in the bottom of the drawers of the medication cart;
-The nurses take care of destroying the medications.
During an interview on 9/23/24 at 3:33 P.M., the Director of Nursing (DON) said:
-He/she expects the CMTs to monitor the medication carts for expired medications, labels that are not readable, and general cleanliness of the medication cart;
-He/she expects the nurses to check the medication carts as well as the CMTs to ensure there are no expired medications, the medication labels are readable and the medication carts are clean;
-The DON should monitor at least every month.
During an interview on 9/23/24 at 3:33 P.M., the Administrator concurred with the DON.
4. Review of Resident #154 admission MDS dated [DATE] showed:
-Brief Interview of Mental Status (BIMS) of 7; indicated moderate cognitive loss
-Able to make self understood and understands others
-Ability to make daily decisions safely is not addressed
-Supervision of staff to maximum assistance of staff for ADLs.
-Diagnoses of Chronic Obstructive Pulmonary Disease (COPD: A group of lung diseases that block airflow and make it difficult to breathe), Chronic Kidney Disease (a condition that occurs when the kidneys are damaged and cannot filter blood properly), Post Traumatic Stress Disorder (PTSD: a mental health condition that can develop after a person experiences or witnesses a traumatic event), Tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe (trachea) to allow air to flow into the lungs), and Barrett's Esophagus (a condition that occurs when the lining of the lower esophagus changes due to stomach acid damage).
Review of the resident's undated care plan showed:
-The resident had a self care deficit;
-No care plan for self administration of medication or storage of medication at bedside.
Review of the physician orders for September 2024 showed:
-Gabapentin Oral Solution (an anticonvulsant and nerve pain medication that can have a sedative effect) give 6 milliliters by mouth three times a day for pain. Ordered 9/12/24;
-Nystatin powder, apply to groin topically three times a day for yeast. Ordered 9/12/24
-No order for resident to keep medications at bedside.
Review of the resident's medical record showed:
-No assessment for self administration of medication.
Observation on 09/16/24 at 1:05 P.M. showed:
-Nystatin powder sitting in the resident's window sill.
-Gabapentin liquid 250 milligram(mg)/5 ml sitting in the resident's windowsill.
-The resident was not in the room
During an interview on 9/23/24 11:19 A.M., RN A said:
-He/She had only one resident that self administered medications;
-Resident #154 should not have his/her medications at bedside;
-Residents must have physician's orders and self-administration of medications assessment completed prior to being able to self-administer their own medications.
During an interview with the DON and the Administrator on 9/23/24 at 3:33 P. M.,
-The DON said, medications cannot be left at bedside without an order. He/She was not aware a resident had Gabapentin, a sedative medication, at bedside.
-The Administrator said, she would not expect medication to be left at bedside without a physicians order and proper assessments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to adequately staff the kitchen with enough dietary staff to ensure meals were served to residents in a timely manner. This has t...
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Based on observation, interview and record review, the facility failed to adequately staff the kitchen with enough dietary staff to ensure meals were served to residents in a timely manner. This has the potential to affect all residents of the facility. The facility census was 104.
1. Review of facility's meal serving policy, dated 12/2/22, showed:
-Check on the resident's at regular intervals;
-Offer additional fluids and water with the meal when there are no fluid restrictions;
Facility did not provide a policy regarding dietary staffing.
Review of the facility's planned meal time schedule dated 9/15-9/28/24, showed:
-Breakfast 7:30 A.M.
-Lunch 11:30 A.M.
-Dinner 5:00 P.M.
Observations on 9/16/24 showed the following:
-11:47 A.M., 19 residents assembled in the dining room for the lunch meal; The dining room had only a few chairs, no place settings, no condiments, no silverware, or centerpieces to indicate a home like environment for the meal time dining experience;
-12:10 P.M., Residents received packets of cream and sugar from staff eight minutes after being served coffee, no utensils were provided to the residents to stir the coffee;
-12:17 P.M., Some residents received metal silverware, some received plastic utensils;
-12:27 P.M., Meals service started in the dining room;
-12:30 P.M., The Administrator from a sister facility assisted with passing drinks in the dining room;
-12:41 P.M., Meal service was completed in the dining room;
-12:50 P.M., The food cart arrived at [NAME] hall; Corporate staff helped to serve the residents noon meal hall trays;
-12:58 P.M., Food cart arrived at Maple hall; Corporate RN staff assisted with meal tray pass;
-1:00 P.M., Environmental Services staff helped pass out trays;
-1:04 P.M., The last tray was served for lunch time service.
Observations on 9/17/24 showed the following:
-8:18 A.M., During breakfast service nothing was provided for residents to use to stir beverages;
-12:04 P.M., 14 residents were sitting in the dining room, no drinks were available and no staff members were in the dining room;
-12:08 P.M., The Activities Director started passing drinks in the dining room. The residents at the first table received one drink cup Kool-Aide which was half full. The residents at the second table received two cups of drinks iced tea and juice;
-12:13 P.M., Residents who requested coffee did not get any;
-12:19 P.M., The Activities Director started passing coffee and creamers, but did not provide any spoons for the residents to stir in the condiments;
-12:31 P.M., The hall meal trays were sent to the dementia unit;
-12:46 P.M., The first meal tray was served in the dining room;
-12:51 P.M., Most residents' drink cups were empty in the dining room, the majority of the residents had not been served lunch and drink refills had not been offered;
-12:59 P.M., No drink refills were offered n the dining room;
-1:12 P.M., Hall trays delivered to [NAME] Hall. The staff were passing out meal trays, but were unfamiliar where each resident was located;
-1:18 P.M., The last meal tray was passed out on [NAME] Hall;
-1:30 P.M., Hall meal trays were delivered to Maple Hall.
Observations on 9/18/24 showed at:
-12:10 P.M., Residents were sitting in the dining room with no drinks or meals;
-12:19 P.M., Hall meal trays were starting to go out, no change in the dining room;
-12:43 P.M., The drinks were being served to the dining room;
-12:45 P.M., Meals were being served in the dining room for lunch service.
Observation of posted meal service times showed:
-Meal times were not posted anywhere in the facility;
-Three lunch services observed, on average the first meal served to the dining room was 69 minutes late.
During an interview on 9/23/24 at 3:30 P.M., the Administrator said:
-Dining room meals times are 7:00 A.M. - 9:00 A.M. Breakfast, 11:30 A.M. - 1:30 P.M. Lunch, and 5:00 P.M. - 6:30 P.M. Dinner;
-She would expect residents to have condiments and utensils readily available for each resident for their coffee.
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** During an interview on 9/23/14 at 3:30 P.M., the Administrator said:
-She would expect residents served coffee to have cream and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 9/23/14 at 3:30 P.M., the Administrator said:
-She would expect residents served coffee to have cream and sugar readily available and utensils for stirring their coffee;
-Would expect residents to have access to clean napkins for each meal;
-She expects that recipes can be done in any order and that the staff are fully competent to add ingredients in any order they choose;
-She expects temperature checks to be done when required;
-She would expect food temperatures checked on the serving line prior to serving the first meals to residents.
Based on observation, interview, and record review, the facility failed to ensure the food served to the residents was palatable, attractive, and at a safe and appetizing temperature when staff did not temperature check cooked foods and recipes were not followed for five (#27, #49, #90, #91, and #96) of 21 sampled residents. In addition, 15 of 20 residents from the resident council group interview said the food was cold and recipes were not followed. The facility census was 104.
1. Review of the facility policy, on Palatability and Nutritive Value, dated 6/27/23, showed:
- Hot foods will be held at temperature 135 degrees or above and cold foods will be held at 41 degrees or below prior to serving to maintain food safety;
- Best efforts will be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary;
- Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns.
Review of the facility policy on Recording of Food Temperatures, dated 9/1/21 showed:
- It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled;
- Hot foods will be held at 135 degrees Fahrenheit or greater;
- Hot foods will be stirred during holding to redistribute heat throughout the food product;
- If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food;
- No food will be served that does not meet the food code standard temperatures.
Review of the facility policy on Food Safety and Sanitation, undated, showed:
-There was no guidance on how to prepare, distribute, and serve food in accordance with professional standards for food safety.
Review of the facility policy on Assistance with Meals, revised September 2013, showed:
-For all residents, hot foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement.
Review of the 9/17/24 lunch menu showed, beef taco with chopped lettuce and tomato, Spanish rice, and chocolate brownie.
Review of the beef taco recipe card, dated 9/17/24, showed:
-Brown beef in skillet until the internal temperature reaches 160 F;
-Drain off fat. Add onions and cook until softened;
-Combine cornstarch and seasonings in a bowl. Add to ground beef and onions. Mix well;
-Add 3 quarts of water to meat mixture. Mix. Simmer for 45 minutes, stirring frequently;
-Place soft taco shells in counter pans. Warm in oven;
-To serve, fill each taco shell with No. 16 dipper of meat mixture;
-Cover meat mixture with lettuce, then tomato, and top with shredded cheese.
Observation of the Beef Taco preparation on 9/17/24 showed:
Cook A completed all the below tasks:
-9:30 A.M., Removed the defrosted beef from the refrigerator, removed packaging, and placed the beef into a large pot.
-9:37 A.M., Added water to the pot with the beef and placed it on a heated stove;
-9:38 A.M., Broke up the beef with a spoon while stirring the water mixture;
-9:42 A.M., Added two containers of unmeasured hot water to the beef/water mixture;
-9:52 A.M., Stirred the beef/water mixture on the stove;
-10:03 A.M., Removed the beef mixture from the stove and poured the liquid into containers sitting on the counter. No temperature checks were taken; No strainer was used.
-10:05 A.M., The pot was placed back on the stove and the beef, with remaining liquid, was stirred;
-10:22 A.M., One spice was added to the beef mixture on the stove and was stirred;
-10:28 -10:32 A.M., Six more seasoning ingredients were added and stirred one at a time into the mixture, the pot was covered with tin foil and placed into a heated oven. No temperature checks or taste testing was done on the mixture.
-10:53 A.M., The taco meat was removed from the oven, an initial temperature check was done which read<160 F
-11:30 A.M., The taco meat container was observed on the serving line covered in foil. The temperature log showed>160 F when placed on the line.
Review of the Spanish [NAME] recipe card, dated 9/17/24, showed:
-Cook rice according to directions;
-Sauté onion, peppers, and celery, cook about 10 minutes;
-Add remaining ingredients (diced tomatoes, Chile sauce, tomato paste, seasonings, 1 quart water) to Sautéed vegetables;
-Combine with cooked rice;
-Place in oven for 1 hour in 12x20 2 pans.
Observation of the Spanish [NAME] preparation on 9/17/24 showed:
Cook A completed the below tasks:
-10:07 A.M., Water was poured into a pot and placed on the stove under heat;
-10:12 A.M., Diced celery was added to the hot water on the stove;
-10:15 A.M., Diced onions were added to the hot water on the stove;
-10:35 A.M., A block of butter without measurement was added to the boiling water containing celery and onions. (The recipe did not have butter as an ingredient but did have vegetable oil for the sauté process which was not followed);
-10:40 A.M., Uncooked rice was added to the boiling water with butter and vegetables;
-10:46 A.M., Diced tomatoes, chile sauce, tomato paste and seasonings were added to boiling rice mixture;
-10:49 A.M., [NAME] A said he/she will know the rice is cooked when it starts to swell up;
-10:56 A.M., Temperature check of the Spanish rice showed 175 F. The mixture was placed into a heated oven to harden up. It was in a soupy state;
-11:13 A.M., The Spanish rice was starting to harden up and lose the watery consistency, temperature check was 180 F, placed on the steam line, and no taste test of the product was completed.
Observation of meal service 9/17/24 showed:
-12:05 P.M., The meal service started, no food items were taste tested and no temperature checks were done from the steam line prior to serving residents.
-12:06 P.M., Tacos are filled with a No. 16 dipper with meat into soft taco shells which were directly taken from plastic storage bag (room temperature), topped with lettuce, and tomatoes. The recipe card called for cheese, but none was added;
-The taco meat appeared watery with a pale grayish white color;
-The Spanish [NAME] showed the correct consistency, however, no taste test or temperature check was done prior to serving;
-Residents were provided rough paper towels for napkins wrapped around the silverware tightly and were wet due to sitting in semi-wet trays on the serving line before being passed to the residents.
Observations of the Test Tray from lunch on 9/17/24 received directly after the last resident was served at 1:31 P.M., showed:
-Taco meat temperature was 105.8 F. The meat was bland, no taste of spices, and watery.
-The taco shell was room temperature, the shell broke apart immediately upon picking it up. The taco, lettuce and tomatoes could only be eaten with a spoon.
2. Review of Resident #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/12/24 showed:
-Resident is cognitively intact;
-Diagnoses of heart failure, hypertension (high blood pressure), diabetes (disease of the pancreas), hyperlipidemia (high cholesterol), anxiety disorder, depression, asthma (inflammation of lung airways);
During an interview on 9/16/24 at 10:16 A.M., the resident said the food is inedible most of the time. He/She has been served moldy hamburger buns, unidentifiable menu items, and bad quality meals with no consistency. The substitutes for hamburgers and hot dogs are equally bad. He/She takes meals in their room and the presentation of the meals is poor.
Review of Resident #49's Quarterly MDS, dated [DATE] showed:
-Resident is cognitively intact.
-Diagnoses of stroke (brain damage), heart failure, hypertension (high blood pressure); diabetes (disease of the pancreas), hyperlipidemia (high cholesterol), hemiplegia (paralysis of one side of the body), depression, and PTSD (fear from a traumatic event or situation).
During an interview on 9/16/24 at 6:30 P.M., the resident said the food is always cold and he/she is not able to chew the food very well. He/She prefers to eat in his/her own room.
Review of Resident #90's Quarterly MDS, dated [DATE] showed:
-Resident is moderately cognitively impaired;
-Diagnoses of stroke (brain damage), hypertension (high blood pressure), hyperlipidemia (high cholesterol), hemiplegia (paralysis of one side of the body);
Review of resident #90's undated care plan showed:
-Resident has difficulty performing ADLs (activities of daily living) and required substantial assistance with eating.
-Resident had dehydration related to poor intake of fluids.
Review of resident's orders, dated 7/10/24, showed:
-Regular diet, mechanical soft texture, nectar thick liquids consistency.
During an interview on 09/16/24 03:58 PM, the resident said:
-The food does not taste good and is so salty that he/she cannot eat it; He/She eats in his/her room;
-The resident's family member said the resident eats in his/her room and is on a mechanical soft diet. The resident's family member said the food is served clumped together, which made it difficult for the resident to get a bite size.
Review of Resident #91's admission MDS, dated [DATE] showed:
-Resident is cognitively intact;
-Diagnoses of anemia (lack of healthy red blood cells), deep venous thrombosis (blood clots), heart failure; hypertension (high blood pressure), renal insufficiency (poor kidney function), obstructive uropathy (urinary tract issues), hip fracture, malnutrition, and asthma (inflammation of lung airways);
During an interview on 9/16/24 10:36 A.M., the resident said the food is often cold and difficult to chew.
Review of Resident #96's Quarterly MDS, dated [DATE] showed:
-Resident is cognitively intact;
-Diagnoses of Debility Cardio-respiratory, heart failure, hypertension (high blood pressure), diabetes (disease of the pancreas), hyperlipidemia (high cholesterol), anxiety disorder, depression, asthma (inflammation of lung airways);
During an interview on 9/16/24 at 11:47 A.M., the resident said the food preparation quality is done poorly, tastes bad as a result, and often times it is served very late. He/She has been living here for five months and the food has always been this way. Instead of a napkin to use with his/her meal they are given soggy paper towels. Sometimes he/she does not get the items that are listed on the menu.
During a group interview of the Resident Council on 9/18/24 at 10:00 A.M., The residents said:
-Food service was their number one complaint at the facility;
-Meals are not served on time and are cold or sometimes burnt;
-Meal tickets are not followed consistently;
-Food service is getting worse;
-They must bring their own spoon if they want to stir cream and sugar into their coffee before it gets cold because utensils take so long to get passed out;
-Some meals are just a clump of food that is unrecognizable.
During an interview on 9/17/24 at 2:00 P.M., the Dietary Manager said:
-She would expect temperature checks to be done as the recipe requires;
-She would expect the recipe followed per the recipe card when preparing meals.
During an interview on 9/23/24 at 9:55 A.M., the Registered Dietician said:
-She would expect food temperatures checked on the steam line right before beginning meal service;
-She would expect temperature checks to be done per the recipe card if it's called for;
-Taco shells should be heated up per the recipe card for the beef taco menu;
-She would not expect hot foods to be held at 135 F when serving hall trays to residents, it's fine as long as it's above 120 F;
-The difference between the serving line of 135 F and the 120 F serving hall requirement is because you're always going to lose heat between serving and getting the trays to the residents, it must be over 120 F.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to manually ...
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Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to manually clean and sanitize kitchen equipment, failed to maintain a clean and sanitary kitchen, failed to wash hands, failed to date and label foods, and failed to wear hair and beard coverings. This had the potential to affect all residents in the facility. The facility census was 104.
1. Review of the facility's policy on three compartment sinks, undated, showed:
- Dishes and cookware will be cleaned and sanitized after each meal;
- Check sanitation sink frequently using a test strip to ensure the level of sanitizing solution is appropriate;
- Sink One Wash: Prepare the clean sink by measuring the appropriate amount of water into the sink and marking the sink with a water line. Determine the appropriate amount of detergent to be used. Water should be 110 F. Change water frequently to ensure effective cleaning of dishes;
- Sink Two Rinse: Prepare the clean sink with hot water;
- Sink Three Sanitize: Measure the appropriate amount of sanitizing chemical into the water. It should be 75 to 100 F. Test the sanitizing solution using test strips. Sanitize according to chart time (not provided).
Review of the facility's policy on sanitizer buckets, undated, showed:
- Sanitation solution will be used on items too large to immerse in sink and areas of production;
- Sanitation buckets are changed as often as necessary, but not to exceed longer than 4 hours.
Observation on 9/16/24 9:00 A.M. showed, the three sink manual washing temperature log was missing for the month of August.
Observation on 9/16/24 at 9:24 A.M. showed, no sanitizing buckets were visible in the kitchen.
Observation on 9/17/24 at 9:12 A.M. showed:
-No temperature checks were documented on the log book for the three compartment sink for September 16th;
-Dietary [NAME] B was observed filling the three compartment sinks and pre-washing cookware without taking any temperatures or testing the sanitizing solution concentration.
Observation on 09/17/24 at 9:23 A.M. showed:
-Cook A washed the cookware in sink one, moved them to sink two, rinsed off the cookware in hot water in sink two, and transferred to sink three.
- 45 seconds later [NAME] A removed the items from the sanitizer sink and placed them on the sink counter to dry. No temperature or sanitizing solution checks were done.
Continuous observation on 9/17/24 from 9:30 A.M. through 1:15 P.M. showed:
- Sanitizing buckets were not changed out after over four hours of use;
- No temperature or sanitizing concentration checks were done over the last four hours. The water was not changed out in any of the sinks.
During an interview on 9/18/24 at 2:15 P.M., the Dietary Manager said:
- She would expect temperature checks for the three-sink manual wash station are taken morning, lunch, and dinner and for each use;
- She would expect the sanitizing buckets to be visible in the kitchen during meal service times.
During an interview on 9/23/24 at 9:55 A.M., the Registered Dietician said:
- She would expect temperatures to be checked prior to washing dishes manually;
- She would expect sanitizing buckets to be stationed throughout the kitchen for all meals.
2. Review of the facility's policy on sanitation inspections, dated 9/1/21, showed:
- All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.
- Daily food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily.
- Weekly, the dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.
- Inspections will be conducted but not limited to the following areas: Dry storage, freezer, refrigerator, dish room, pot wash, main production area, food preparation area, general dietary observations.
Observation on 09/16/24 08:59 AM, in the kitchen showed:
- Excessive dust and dirt on the ventilation ducts;
- Floors were sticky throughout the kitchen, storage areas and cleaning stations;
- Accumulation of dust/dirt on the wall next to the refrigerator;
- Accumulation of dust, dirt, screws, and lint on top of the freezer;
- Vent duct overhead had an accumulation of lint;
- Two ovens had old burned food debris inside;
- Behind the stove there was a dirty oven shelf grate lying on the floor;
- Behind the stove there was a large quantity of food and grease build up;
- Vents behind the stove were covered in exhaust dust;
- Food splatter on the slicer;
- The microwave had old food splattered inside;
- Paint was missing and debris and dirt build up near the 3 three compartment sink;
- Surface area, where plates were staged at the steam line for serving, were noted to have visible old food debris;
- Walls were dirty throughout the kitchen area, with dried food on the walls and ceiling surfaces;
- The top of the tea machine had sticky dried liquid and debris;
- The juice machine had dust on the exhaust fans;
- Liquid had dripped onto the floor below the tea station;
- Cut off plastic ties were lying on the kitchen floor.
Observation on 09/16/24 09:15 A.M., of the dry storage room showed:
- Loose ceiling material was hanging, a potential contamination risk;
- Dust build up on the walls.
Observation on 09/16/24 09:22 A.M., of the cleaning closet showed:
- Cluttered floor with dust pans and tools, a possible harbinger for rodents and insects;
- Sink was rusted;
- Shelves had visible debris on top of them and an accumulation of dust;
- Lint and dust were on the vents and walls.
Observation on 9/16/24 10:25 A.M., in the dining room showed:
- Orange substance build up over the internal metal lip right above the ice dispensing chute inside the ice machine;
- Trash can without a lid, stored in the dining room containing food debris and trash;
- Floor going into the kitchen had visible dirt and grime build up.
Observation on 09/17/24 at 12:22 P.M. showed:
-Cook C emptied cut up tomatoes directly into a container on the steam line from a large cutting board. The bottom surface of the cutting board made contact with the inside of the food serving container as the food transfer was made causing potential cross contamination.
During an interview on 9/18/24 at 2:15 P.M., the Dietary Manager said:
- The floors are sticky because they needed to be waxed;
- Dust and dirt on the ventilation ducts should be cleaned;
- The top of the freezer surface area should be free of dust, dirt, screws and lint;
- The kitchen in its current state is clean and up to their standards;
- He/She would not expect ovens to have old food debris;
- He/She would not expect the cleaning closet to be cluttered and strewn with cleaning tools on the floor;
- He/She would expect the ice machine to be free of dirt buildup inside the machine;
- He/She would expect lids on all trash cans.
During an interview on 9/23/24 at 9:55 A.M., Registered Dietician said:
- She would expect deep cleaning around equipment and kitchen surfaces to be done weekly and that there is a cleaning schedule posted;
- She would expect ventilation openings to be free of dirt and dust build up.
3. Review of the facility's policy on handwashing guidelines for dietary employees, 9/1/2021, showed:
- The facility shall provide a handwashing sink(s), with supply of hand cleaning solutions, in a location that is convenient for use by employees in food preparation, food dispensing, ware washing areas and in or immediately adjacent to toilet rooms.
- Frequency of Handwashing: (a) After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, (b) after hands have touched bare human body parts other than clean hands (such as face, nose, hair), (c) while preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, (d) before donning (applying) gloves for working with food, (e) after engaging in any activity that may contaminate the hands.
- Handwashing procedure: turn on water to a comfortable warm temperature, rinse thoroughly under clean, running warm water.
Observation on 9/16/24 at 9:00 A.M., showed, the cold-water faucet did not work and only hot water came out at the sink.
Observation on 9/17/24 at 9:28 A.M., showed [NAME] A did not wash his/her hands after working in the sink area before applying gloves and working with meat.
Observation on 9/17/24 at 9:30 A.M. showed:
- [NAME] A moved beef from the defrosting stage in the refrigerator to the prep area and opened all beef packages, disposed of trash, put utensils into wash sink, and removed gloves;
- [NAME] A added water to the pan with meat, and had not washed his/her hands since working with raw meat and removing gloves.
Observation on 09/17/24 at 10:08 A.M. showed, [NAME] A did not wash hands before applying gloves after working at stove area, and then went to the prep area and chopped up green peppers.
Observation on 09/17/24 at 12:27 P.M. showed:
- [NAME] C chopped and prepared a hot dog by wrapping it in tin foil while wearing gloves;
- [NAME] C wiped his/her gloved hands off on their apron so he/she could use a pen to write on the product wrapping;
- [NAME] C then started preparing a 2nd hot dog with the same gloves, pulled out a bun and filled it with a hot dog with the gloved hands then changed the gloves.
Observation on 09/17/24 12:45 P.M. showed, [NAME] C stopped cutting tomatoes and went to the back office with gloves on and picked up and delivered a box of tea to a staff member at the kitchen door. [NAME] C then removed both gloves, put on new gloves, did not wash hands, and went back to the food prep area to prepare a hamburger. [NAME] C used a gloved hand to catch burger grease/water as he/she walked the item across the kitchen then started working on dicing tomatoes with the same gloved hands.
During an interview on 9/23/24 at 9:55 A.M., the Registered Dietician said, he/she would expect hot and cold water at the handwashing station.
4. No policy on the requirement for hair and beard coverings was provided.
Observation on 09/17/24 at 12:04 P.M. showed:
- Dishwashing Aide A not wearing a beard covering over moustache;
- Maintenance staff entered the kitchen without a hairnet covering.
Observation on 09/17/24 at 1:12 P.M. showed:
- [NAME] A wore a beard covering below the chin while working with food in the kitchen.
5. Review of facility's policy on food storage, undated, showed:
- All food stock and products are stored in approved sanitary storage containers, of food quality plastic bags, covered, labeled as to contents, and dated.
Review of facility policy, food storage (dry, refrigerated, and frozen), undated, showed:
- Goods that have been opened with no date, left on the floor, or not properly sealed will be discarded;
- Dry goods: food stored in bins are removed from original packaging. Bins are labeled and dated. All open products are sealed, labeled, and dated;
- Refrigerated foods: open products are sealed, labeled, and dated;
- Frozen foods that are taken out of original packaging, product is labeled and dated.
Observation on 09/16/24 at 0910 A.M. showed:
- Loose frozen hash browns in a plastic bag in the freezer with no date or label;
- Loose pie shell in a plastic bag in the freezer with no date or label;
- One shelf of bread not labeled with a date;
- No date or label on raw onion bin;
- No date on an oatmeal pie box opened.
During an interview on 9/18/24 at 2:15 P.M., the Dietary Manager said:
- Unlabeled bags in the freezer should be labeled and have a date written on them with a magic marker but the marker wears off. They are looking for other solutions;
- Vegetables such as red onions kept in a bin should have a sticker with a date on it which is their normal process.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to maintain all areas of the facility in a safe, functional, sanitary and comfortable environment for visitors, staff and reside...
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Based on observation, record review, and interview, the facility failed to maintain all areas of the facility in a safe, functional, sanitary and comfortable environment for visitors, staff and residents. The facility census was 104.
Review of the facility provided policy Routine Cleaning and Disinfection dated 9/1/21 showed:
-It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment.
-Cleaning refers to the removal of visible soil from objects and surfaces.
-Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine areas should be cleaned on a regular basis; when soiling or spills occur; when a resident is discharged .
-Cleaning of walls, blinds and window curtains will be conducted when visibly soiled.
Review of the facility provided, undated, policy Safe and Homelike Environment included, in accordance with resident rights the facility will provide a safe, clean, comfortable and homelike environment.
Observations beginning on 09/16/24 at 12:58 P.M. on [NAME] Hall showed:
-Large cobwebs with dead bugs at the corner of the exit door;
-Wall paper trim was bubbled and coming off the walls;
-The exit door was rusted in multiple places with visible daylight at the bottom on the latch side;
-Multiple gouges and nicks in the wallpaper on the upper 2/3 of the hallway, with spackle over them;
-Cobwebs on the air vent;
-Multiple light fixtures with dead bugs and debris;
-Multiple ceiling tiles surrounding air vent, with brown water stains, outside room B9;
-Multiple mechanical hand sanitizer drip trays with dirt, debris and dead bugs.
Observation of the Director of Nursing Office showed:
-Light fixtures with dead bugs and debris;
-Cobwebs in the corners with dead bugs and debris;
-Gouges and scrapes in the sheet rock.
Observation on 09/18/24 at 12:33 P.M. showed on the Special Care Unit:
-Entry door push bar was loose from the door panel on both sides of the door;
-Entry door was scuffed with black scuff marks;
-Tiled floor had multiple scratches and black scuff marks;
-Baseboards in the dining area had thick black debris along the floor line;
-The dining room window blinds were broken and jagged, with zip ties holding them to the window sill;
-The air conditioning units, in the dining room, were loose from the wall;
-The ceiling vent was covered with dirt, dust and black debris;
-The wallpaper was peeled and bubbled away from the wall;
-The ceiling vent outside room E25 was coated with dirt and dust;
-The ceiling above the nurses station had 2 lights burned out, both had dirt and debris;
-The nurses station desk was chipped in eight places;
- The outlet cover was broken and the floor in that area was dirty with dirt and debris;
- The shower room curtain had dirt, debris and black mold like substance on both sides;
-The baseboards were warped and curved away from the wall, had dirt and debris at edges, and were missing at the nurses station;
-No window screen in Room E1.
During an interview on 09/23/24 at 7:33 A.M., Housekeeper A said:
-He/She completed daily cleaning of the resident bathrooms, and mops the floor;
-One person cannot complete everything that needed to be completed;
-There is a floor technician in the evening to buff floors;
-There was no check off list for completed tasks.
During an interview on 09/23/24 at 8:17 A.M., the Housekeeping Supervisor said:
-The Administrator expects the facility to be clean and odor free;
-Cleaning is completed daily by a list;
-He/She expects the facility to be clean, odor free and floors and ceilings to be free of dirt and debris.
During an interview on 9/23/24 at 9:11 A.M., the Maintenance Director said:
-He had been employed in the facility four months;
-Morning meetings are where he finds out repairs that are needed, or staff can fill out a work order;
-He knew of the broken window a few days ago;
-He completed weekly walk through inspections with Administration;
-He tried to paint over some of the water damage after walk through with investors;
-He tried to find leaks and fix them as he can;
-He expects things to be in good repair;
-The baseboards are paint stained. Housekeeping is responsible for cleaning baseboards;
-Repairs are prioritized by need;
-Housekeeping is responsible for all floors, dusting and baseboard cleaning;
-Maintenance is responsible for light fixture cleaning, and repair;
-Vents are maintenance responsibility; he has not seen anything that looks like mold; filters are changed once a month;
-He used a log book to know what needs fixed. If it was not on the log then it would not be fixed;
-Log books were at each nurses station and any staff can write in them.
During an interview on 9/23/24 at 3:33 P.M., the Administrator said:
-Housekeeping was to complete daily cleaning to include dusting and high dusting;
-She expected the facility to attempt to be odor free as much as possible;
-Vents, floors and ceilings should be cleaned by housekeeping and maintenance as a collaborative effort;
-Anyone can put a work order in if something is broken;
-Each Department Head completes weekly rounds and would make a note of any issues that need addressed by a different department;
-She would expect work orders to be completed if the department head found a concern for maintenance;
-They have made progress in the cleanliness of the building but had more to go.
Feb 2024
3 deficiencies
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 F0557
(Tag F0557)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Please refer to Event ID 45RI12 for additional details.
Based on observations, interviews and record review, the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Please refer to Event ID 45RI12 for additional details.
Based on observations, interviews and record review, the facility failed to ensure staff provided care in a manner to preserve and enhance residents' dignity when staff did not ensure call lights were within reach for three residents(Residents #100, #9, and #40), when staff did not respond to call lights timely for one resident (Resident #19), and when staff moved two residents' personal belongings without them being present (Resident #7 and #58). This affected seven of 28 sampled residents. The facility census was 82.
Review of the facility's Resident Rights policy, revised 9/1/22, showed:
-The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
-The right to receive services and/or items included in the plan of care;
-The resident has a right to be treated with respect and dignity;
-The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.
-The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Review of facility policy, Call Lights: Accessibility and Timely Response, dated 9/1/21, showed:
-The purpose of policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or a centralized location to ensure appropriate response.
-With each interaction in the resident's room or bathroom, staff will ensure the call light system is within reach of resident and secured, as needed.
-All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.
1. Review of Resident #32's annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/9/24, showed:
-Brief Interview Mental Status (BIMS) of 15, a cognitive screening tool used by long term care to determine mental status, indicating the resident was cognitively intact;
-Required substantial/maximal assistance with toileting, hygiene, bathing, and lower body dressing;
-Required supervision or touching assistance with mobility;
-Diagnoses included diabetes, arthritis, anxiety disorder, depression, and adjustment disorder (a condition causing excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior).
Review of the resident's care plan, dated 11/15/23, showed:
-Staff to intervene as necessary to protect the rights and safety of others. Approach and speak to the resident in a calm manner, divert attention, and remove from situation and take to alternate location as needed.
-Ensure the resident's call light is within reach and encourage resident to use it for assistance as needed. Resident requires prompt response to all requests for assistance.
During an interview on 2/5/24 at 1:15 P.M., Resident #32 said:
-His/Her roommate, Resident #40, had been abusing the privilege of having access to a call light;
-He/She currently had both call lights in his/her possession due to the roommate abusing the privilege of the call light for his/her convenience;
-He/She notified nursing staff that he/she would watch Resident #40 for them since Resident #40 was driving them nuts pushing his/her call light constantly;
-Staff handed the call light over to him/her to monitor;
-He/She had been in control of the call light for a couple of weeks now.
Review of Resident #40's annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/26/23, showed:
-BIMS score of 10, indicating moderately impaired cognition;
-Required substantial or maximal assistance with shower and bathing self, lower body dressing, sitting to standing mobility, chair to bed transfers;
-Required partial or moderate assistance with toileting hygiene, toilet transfers, and moving from lying to sitting on the side of the bed;
-Used manual wheelchair;
-Diagnoses included hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (one sided muscle weakness) following stroke affecting left-non-dominant side, generalized muscle weakness, sensorineural hearing loss (the inner ear nerve responsible for transmitting sounds are damaged), and metabolic encephalopathy (condition that can lead to personality changes).
Review of Resident #40's care plan, dated 10/10/22, showed:
-Be sure call light is within reach and encourage him/her to use it for assistance.
Observation on 2/5/24 at 2:01 P.M., showed the call light not in reach. Resident #32 had Resident #40's call light button.
2. Review of Resident #100's admission MDS, dated [DATE], showed:
-BIMS of 00, indicating undetermined cognitive status;
-Dependent for personal hygiene, dressing, bathing, toileting, oral hygiene;
-Required substantial/maximal assistance to roll left to right;
-Diagnoses included arthritis, osteoporosis (a condition causing bones to become weak and brittle), and pervasive developmental disorder (a condition characterized by delays in development of social and communication skills).
Review of the resident's care plan, dated 12/18/23, showed:
-Encourage the resident to use bell to call for assistance.
Observation on 2/5/24 at 2:20 P.M., showed the call light was laying on the floor along the wall under the call light plug and was not in reach while the resident lay in bed.
3. Review of Resident #9's annual MDS, dated [DATE], showed:
-BIMS of 14, indicating cognitively intact;
-Had impairment on one side on upper extremity and impairment to both sides on lower extremities;
-Required wheelchair for mobility;
-Was dependent for oral care, toileting, bathing, dressing, and mobility;
-Diagnoses included stroke (a condition resulting from damage to the brain from interruption of its blood supply), dementia (a group of thinking and social symptoms that interferes with daily functioning), traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), and contractures of joints.
Review of resident's care plan, dated 1/3/24, showed:
-Ensure call light is within reach.
Observation on 2/5/24 at 2:29 P.M., showed the call light was laying on the floor at the head of the bed and not in reach of the resident.
During an interview on 2/5/24 at 2:29 P.M., the resident said:
-He/She could not reach the call light.
4. Review of Resident #19's quarterly MDS, dated [DATE], showed:
-BIMS of 14, indicating cognitively intact;
-Dependent for toileting hygiene and lower body dressing;
-Required substantial/maximal assistance for bathing and mobility;
-Diagnoses included diabetes, urinary tract infection, generalized muscle weakness, rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in hands and feet), fibromyalgia (a long term condition that involves widespread body pain and tiredness), and lack of coordination.
During an interview on 2/5/24 at 2:31 P.M., the resident said:
-It sometimes took staff thirty minutes to answer his/her call light;
-Call light wait times had caused him/her to sit in wet briefs;
-Having to be incontinent of urine makes him/her feel neglected, uncomfortable, and itchy.
5. Review of Resident #7's quarterly MDS, dated [DATE], showed:
-BIMS of 15, indicating cognitively intact;
-Independent with toileting, personal hygiene, dressing, rolling left to right;
-Diagnoses included diabetes, low back pain, and opioid dependence (reliance on prescription pain medications).
Review of the resident's care plan, dated 1/3/24, showed:
-The resident has the right to be treated with consideration, respect, and dignity.
During an interview on 2/22/24 at 2:51 P.M., the resident said:
-Facility staff came into his/her room while he/she was not present and removed personal items off the top of his/her light and threw them on the bed;
-His/Her night table was turned so he/she could not access the drawers and was blocked by the edge of the bed;
-Facility staff told him/her to get rid of his/her stuff;
-Facility staff did not treat him/her like the facility was his/her home.
6. Review of Resident #58's quarterly MDS, dated [DATE], showed:
-BIMS of 15, indicating cognitively intact;
-Required substantial/maximal assistance with toileting hygiene, rolling left to right, and putting on and taking off footware;
-Required partial to moderate assistance with dressing his/her lower body;
-Diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), unsteadiness on feet, and generalized muscle weakness.
During an interview on 2/6/24 at 11:48 A.M., the resident said:
-The Social Services Director and Certified Nurse Aide (CNA) B came into the resident's room and moved his/her belongings while he/she was in the bathroom without his/her permission;
-His/Her personal items were placed in totes and items were removed from under the bed;
-He/She now cannot find personal stuff and some letters are missing;
-He/She felt frustrated that his/her personal items were gone through without his/her permission or being present.
7. During an interview on 2/6/24 at 12:01 P.M., CNA A said:
-The facility usually only has one aide working on the Maple and [NAME] halls;
-Call lights should be within a resident's arm reach or clipped to the resident;
-Resident #32 took Resident #40's call light stating he/she was tired of the staff's voice coming into room;
-He/She was aware that Resident #32 took the call light before 1:20 P.M. on 2/5/24;
-When he/she enters Resident #40's room, he/she will ensure the call light is back on the other resident's side of the room and within reach.
During an interview on 2/6/24 at 12:49 P.M., CMT A said:
-Call lights should be clipped to the bed or within reach such as being clipped to a resident's gown.
During an interview on 2/12/24 at 3:45 P.M., the Administrator said:
-Call lights should be answered in a reasonable time;
-Call lights should be within reach of the resident;
-Call lights should not be held and maintained by a resident's roommate, that is not appropriate.
-Residents have the right to their own personal belongings;
-When facility staff were going through and moving things off the top off closets we notified residents and offered totes so residents had a better way to store personal items;
-Facility staff talked to residents two to three days before completing deep cleaning;
-It is not appropriate to move a resident's belongings without the resident present or involved in the process.
MO230743
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to Event 45RI12 for SOD.
This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to Event 45RI12 for SOD.
This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated 12/14/23.
Based on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to keep all areas of resident rooms and hallways clean, did not keep trash picked up off the floor, keep floors free of dirt and grime, and wipe down over-bed tables. The facility census was 82.
Review of facility policy, Routine Cleaning and Disinfection, dated 9/1/21, showed:
-Ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to extent possible;
-Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products.
1. Observation on [NAME] hall on 2/5/24 at 8:05 A.M., showed:
-Spilled coffee and brown fecal material on the floor in front of the nurses station and gum stuck to the floor;
-room [ROOM NUMBER] with food, pieces of dirt, a wrapper, and a menu on the floor;
-room [ROOM NUMBER] had pieces of food, mud, and a spilled sticky substance on the floor. The bedside table had food pieces all over the top;
-The floor in room [ROOM NUMBER] was black in color with dirt covering it.
2. Observation on Maple hall on 2/5/24 at 8:09 A.M., showed:
-Black lines down the main hallway from dirt and grime;
-Dried spilled coffee stains across the floor down the entire hallway.
3. Observation in the dining room on 2/5/24 at 8:30 A.M., showed the piano had a white powder dust-like material across the top.
4. Observation of room [ROOM NUMBER] on Maple hall on 2/5/24 at 2:08 P.M., showed:
-The floor with pieces of breakfast cereal, streaks of mud, and dirt.
5. Observation of room [ROOM NUMBER] on [NAME] hall on 2/5/24 at 2:20 P.M., showed:
-The over-bed table was covered with pieces of food;
-Mud and pieces of cake on the floor.
6. Observation of room [ROOM NUMBER] on Village hall on 2/6/24 at 8:59 A.M., showed:
-The floor was sticky and feet stuck to the floor when walking.
During an interview on 2/16/24 at 3:45 P.M., the Administrator said:
-Mondays are a rough day for environment in the facility due to management not being in building all weekend to ensure cleaning was done;
-Environmental staff who were in the facility to clean over the weekends are off work on Mondays;
-Facility floors should not be black;
-There should not be food piled on the floor;
-Items should not be covered in powder-like substances.
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 F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to SOD at 45RI12
This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 12/14/23.
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to SOD at 45RI12
This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 12/14/23.
Based on observation, interview, and record review, facility staff failed to provide dressing, shaving, grooming, and bathing assistance for four of 26 sampled residents (Residents #3, 100, #19, and #33). The facility census was 82.
Review of facility policy, Activities of Daily Living (ADLs), dated 9/1/21, showed:
-The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable;
-The facility shall provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment;
-A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
-The facility will maintain individual objectives on the care plan and periodic review and evaluation.
Review of facility policy, Resident Showers, dated 9/1/21, showed:
-Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety;
-Partial baths may be given between regular shower schedules as per facility policy.
1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/21/23, showed:
-BIMS score of 15, which indicated the resident was cognitively intact;
-Required set up or clean up assistance for eating, oral hygiene, and personal hygiene;
-Required partial to moderate assistance with bathing;
-Diagnoses included diabetes, stroke (damage to the brain from the interruption of blood supply), depression, history of falling, cognitive communication deficit, and mild intellectual disability.
Review of the resident's care plan, dated 10/10/23, showed:
-The resident prefers showers in the morning twice weekly;
-The resident prefers to be shaved on shower days;
-The resident wants hair washed during shower days.
-The resident has an ADL performance deficit due to dementia and mild intellectual disability;
-Check the resident's nail length and trim and clean on bath days and as necessary;
-The resident has dentures and requires assistance with denture care.
Observation on 2/5/24 at 8:22 A.M., showed the resident had 1/4-1/2 inch hair on his/her face and was not shaved. He/she wore a hat that was stained with discoloration from sweat or grease, his/her hair stuck out from the hat in all different directions, and thick dandruff on his/her shoulders. The resident's clothes were stained and disheveled.
During an interview on 2/5/24 at 1:15 P.M., the resident said:
-He/She wanted to get a shower;
-Monday and Thursday evenings are his/her shower days;
-He/She liked to be shaved;
-He/She needed to shower that day.
Observation of the resident on 2/6/24 at 8:47 A.M., showed:
-The resident unshaven, hair going all different directions, and stains on his/her clothes.
Review of the resident's shower logs from 1/15/24 to 2/5/24 showed:
-1/16/24, the resident received a shower from CNA H, but no hair washing or shaving was provided;
-1/25/24, the resident received a shower from CNA G, but no hair washing or shaving was provided;
-2/2/24, the resident received a shower from unknown CNA, but no hair washing or shaving was provided.
2. Review of Resident #100's admission MDS, dated [DATE], showed:
-BIMS of 00, indicating undetermined cognitive status;
-The resident was dependent on facility staff for personal hygiene, dressing, bathing, toileting, oral hygiene;
-The resident required substantial/maximal assistance to roll left to right;
-Diagnoses included arthritis, osteoporosis (a condition causing bones to become weak and brittle), and pervasive developmental disorder (a condition characterized by delays in development of social and communication skills).
Review of the resident's care plan, dated 1/18/24, showed:
-The resident had an ADL self-care performance deficit;
-The resident was totally dependent on one staff to provide bath/shower as necessary;
-The resident required extensive assistance of one staff for personal hygiene and oral care.
Observation of the resident on 2/5/24 at 2:20 P.M., showed:
-The resident had approximately 1/2 inch long facial hair on his/her chin;
-The resident was dressed in a hospital gown.
During an interview on 2/5/24 at 2:20 P.M., the resident said:
-He/She did not have clothes, just pajamas;
-He/She would like to get dressed;
-The facility had shaved him/her one time.
Observation of the resident on 2/6/24 at 12:35 P.M., showed:
-The resident was up in a wheelchair.
-His/Her hair was braided;
-Chin hair measured approximately 1/2 inch long.
Review of the shower shower logs from 1/15/24 to 2/5/24 showed:
-1/17/24 the resident refused shower from CNA J- however CNA J was not on the daily staffing sheet for that day;
-1/19/24 the resident refused shower from CMT C- however CMT C was not on the staffing sheet for that day;
-1/20/24 the resident was showered by CMT C, but no shaving or hair washing was provided;
-1/23/24 the resident was showered by CMT C, but no shaving or hair washing was provided;
-1/27/24 the resident was showered by CMT C, but no shaving or hair washing was provided - however CMT C was not on the staffing sheet for that day;
-1/30/24 the resident was showered by CNA J, but no documentation that shaving or hair care was completed;
-2/4/24 the resident refused a shower from CMT C- however CMT C was not on the staffing sheet for that day.
3. Review of Resident #33's quarterly MDS, dated [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The resident is independent for eating;
- Requires set up assistance for oral hygiene,
- Supervision for personal hygiene;
- Moderate assistance for bathing;
- Substantial assistance for toileting hygiene, upper and lower body dressing, tolling left and right, sitting to lying, lying to sitting, sitting to standing, and all transfers;
- Dependent on staff for putting on and taking off footwear;
- Frequently incontinent of urine;
- Always incontinent of bowel;
- Diagnoses of Hemiplegia (paralysis of one side of body) after a stroke, cognitive communication deficit, difficulty walking, need for assistance with personal care, and seizures.
Review of the resident's care plan, revised 10/30/23, showed:
- The resident had an ADL self care deficit related to hemiplegia and a stroke;
- Staff should assist with ADLs as needed;
- The resident needed assistance with transfers;
- No information on required assistance with showers or bathing.
During an interview on 2/5/24 at 3:45 P.M., the resident said:
-He/She was not receiving regular showers;
-His/Her last shower was on 1/30/24 (six days ago);
-He/She would like a shower daily;
-He/She felt icky when he/she did not receive showers.
Review of the resident's shower logs from 1/15/24 to 2/5/24 showed:
-On 1/19/24, the resident received a shower from CMT C, but did not document shaving or washing the resident's hair- however CMT C was not on the staffing sheet for that day;
-On 1/22/24, the resident received shower from CMT C, but did not document shaving or washing the resident's hair- however CMT C was not on the staffing sheet for that day;
-On 1/24/24, the resident received shower from an unidentified CNA;
-On 1/30/24, the resident received shower from CNA L;
-On 2/2/24, the resident received shower from CMT C, but did not document shaving or washing the resident's hair- however CMT C was not on the staffing sheet for that day.
4. Review of Resident #19's quarterly MDS, dated [DATE], showed:
-BIMS of 14, which indicated resident was cognitively intact;
-The resident was dependent for toileting hygiene and lower body dressing;
-The resident required substantial/maximal assistance for bathing and mobility;
-Diagnoses included diabetes, urinary tract infection, generalized muscle weakness, rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in hands and feet), fibromyalgia (a long term condition that involves widespread body pain and tiredness), and lack of coordination.
During an interview on 2/5/24 at 2:31 P.M. the resident said:
-He/She was not getting showers;
-The last shower received was at least five weeks ago;
-He/She has only refused one shower- and it was offered at 1:45 A.M.;
-The shower system needs major improvement;
-He/She would like a shower at least one time a week;
-He/She was supposed to receive showers on Thursdays at 11:00 A.M.;
-He/She had not even been offered a shower.
Review of the resident's shower logs from 1/15/24 to 2/5/24 showed:
-On 1/17/24, the resident received shower from CMT C, but no shaving or hair washing provided;
-On 1/19/24, the resident received shower and shaving from CMT C, but no hair washing documented- however CMT was not on the daily staffing sheet for that day;
-On 1/22/24, the resident received shower from CMT C, but no shaving or hair washing documented- however CMT C was not on the daily staffing sheet for that day;
-On 1/24/24, the resident refused shower from an unidentified staff member who did not sign the shower sheet;
-From 1/26/24 to 2/2/24 the resident was hospitalized ;
-On 2/2/24, the resident refused a shower from an unidentified staff member who did not sign the shower sheet.
During an interview on 2/6/24 at 12:49 P.M., CMT C said:
-He/She may have helped with a shower for the resident but he/she did not remember.
5. During an interview on 2/6/24 at 12:01 P.M., CNA K said:
-When he/she works on the hall alone, he/she cannot get scheduled showers done;
-He/She worked by him/herself most of the time;
-Usually one aide was scheduled on the day shift for [NAME] Hall and one aide on Maple hall. Occasionally a float staff person is scheduled to go between halls and complete showers;
-He/She was hired as a shower aide but has yet to become the shower aide;
-He/She works on Maple or [NAME] halls mostly;
-When a resident refused a shower, the facility had the resident sign the shower sheet;
-He/She performs grooming of residents on shower days and documents grooming completed on shower sheet.
During an interview on 2/6/24 at 12:49 P.M., CMT C said:
-He/She was a medication technician on [NAME] hall and was not a shower aide;
-He/She did not usually give showers in the facility;
-He/She helped once or twice with showers but did not typically complete them;
-The facility is staffed on a bad day with one medication technician, one nurse, and no aide or an aide 7:00 A.M.-3:00 P.M. and no aide from 3:00 P.M.-7:00 P.M. and this occurs one to three times each week.
During an interview on 2/12/24 at 3:45 P.M., the Administrator said he/she expected the following:
-Residents to be clean and comfortable;
-Residents to be offered shaving and grooming with their showers;
-Showers to be offered twice weekly;
-Residents to be redirected if they refused showers;
-Staff to ask residents if there was a better time and a reason why when resident refused showers;
-Staff to have someone else offer shower to resident if resident refuses;
-Resident and aide to sign shower sheet when shower was refused;
-Shower refusals to be documented;
-Residents should be offered to get dressed daily;
-Residents to wear clean clothes;
-Care plans to be updated for residents that were resistive to care.
During an interview on 2/12/24 at 4:01 P.M., the Director of Nursing (DON) said:
-The facility went through every resident and made shower schedules based off their preferences;
-Staff should offer showers based on the schedule provided;
-The facility had shower sheets that the resident could sign when they refused a shower;
-Staff should notify the charge nurse if resident refused a shower;
-He/She is often made aware of residents refusing;
-Showers could always be offered another time.
Dec 2023
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an annual dental exam for one sampled resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an annual dental exam for one sampled resident (Resident #15) and additionally failed to provide a dental consult for resident #15 who was requesting to be evaluated for replacement dentures for over one year. The facility census was 82 residents.
1.Review of resident #15's quarterly Minimum Data Set (MDS) dated [DATE] showed:
-Resident with a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment.
-Diagnosis of dementia (a condition characterized by progressive or persistent loss of intellectual functioning).
-Oral and Dental Status not completed on MDS.
-Resident was independent eating, ambulation, and dressing.
Review of resident's Care Plan, initiated 4/19/21 and revised on 10/10/23., showed:
-Change in dentition and/or oral hygiene.
- The resident does not have teeth and would like dentures.
- Goals included: Dentures to be obtained by next review date, to be able to chew food sufficiently, and be able to eat and drink without pain.
- Interventions include, refer to dentist/dental hygienist for evaluation and recommendations.
Review of Resident #15's Electronic Medical Record (EMR) showed:
-The resident was admitted to facility on 4/2/21.
-No documented dental visits since admission.
During an interview on 12/11/23 at 10:30 A.M., the resident said:
- Someone took his/her dentures when he/she first was admitted to facility.
-He/she had trouble chewing some foods and this makes his/her gums sore.
-He/she would like to eat different things but is not able to without dentures.
-He/she had dentures for several years, prior to admission.
-He/she would like to get new dentures.
During an interview on 12/13/23 at 9:45 A.M., Social Service Director said:
-Resident has an appointment on 1/15/23 with a local dental care provider.
-Resident received dental care in the past. When asked to provide documentation of that dental visit, Social Service Director stated that he/she can't find the note.
During an interview on 12/13/23 at 10:20 A.M., the scheduler for the local dental provider said:
-Someone from the facility called about this yesterday and they were demanding an appointment for the resident. An appointment for dental services on 1/15/23 was made on 12/12/23.
-They had not seen/treated the resident previously.
During an interview on 12/13/23 at 10:40 A.M., Scheduler for dental provider A said the resident has never had care with them.
Observation on 12/13/23 at 10:45 A.M., Social Service Director provided a sticky note with information regarding an appointment with a dentist for the resident. An appointment is scheduled for 12/15/23.
During an interview on 12/13/23 at 10:50 A.M., Dentist A, an independent dental practitioner said:
-He/she was contacted today 12/13/23 by the facility to set up an appointment for resident.
- An appointment is scheduled for 12/15/23 to obtain impressions for dentures.
During an interview on 12/14/23 at 5:21 P.M., the Director of Nursing (DON) said, treatments should be completed per physician orders.
During an interview on 12/14/23 at 5:25 P.M., the Administrator said, residents who need dental care should have these services provided to them, and should not have to wait for a year.
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 F0557
(Tag F0557)
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 provided care in a manner to preserve a...
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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 care in a manner to preserve and enhance residents' dignity when staff did not ensure call lights were within reach for three residents(Residents #100, #9, and #40), when staff did not respond to call lights timely for one resident (Resident #19), and when staff moved two residents' personal belongings without them being present (Resident #7 and #58). This affected seven of 28 sampled residents. The facility census was 82.
Review of the facility's Resident Rights policy, revised 9/1/22, showed:
-The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
-The right to receive services and/or items included in the plan of care;
-The resident has a right to be treated with respect and dignity;
-The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.
-The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Review of facility policy, Call Lights: Accessibility and Timely Response, dated 9/1/21, showed:
-The purpose of policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or a centralized location to ensure appropriate response.
-With each interaction in the resident's room or bathroom, staff will ensure the call light system is within reach of resident and secured, as needed.
-All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.
1. Review of Resident #32's annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/9/24, showed:
-Brief Interview Mental Status (BIMS) of 15, a cognitive screening tool used by long term care to determine mental status, indicating the resident was cognitively intact;
-Required substantial/maximal assistance with toileting, hygiene, bathing, and lower body dressing;
-Required supervision or touching assistance with mobility;
-Diagnoses included diabetes, arthritis, anxiety disorder, depression, and adjustment disorder (a condition causing excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior).
Review of the resident's care plan, dated 11/15/23, showed:
-Staff to intervene as necessary to protect the rights and safety of others. Approach and speak to the resident in a calm manner, divert attention, and remove from situation and take to alternate location as needed.
-Ensure the resident's call light is within reach and encourage resident to use it for assistance as needed. Resident requires prompt response to all requests for assistance.
During an interview on 2/5/24 at 1:15 P.M., Resident #32 said:
-His/Her roommate, Resident #40, had been abusing the privilege of having access to a call light;
-He/She currently had both call lights in his/her possession due to the roommate abusing the privilege of the call light for his/her convenience;
-He/She notified nursing staff that he/she would watch Resident #40 for them since Resident #40 was driving them nuts pushing his/her call light constantly;
-Staff handed the call light over to him/her to monitor;
-He/She had been in control of the call light for a couple of weeks now.
Review of Resident #40's annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/26/23, showed:
-BIMS score of 10, indicating moderately impaired cognition;
-Required substantial or maximal assistance with shower and bathing self, lower body dressing, sitting to standing mobility, chair to bed transfers;
-Required partial or moderate assistance with toileting hygiene, toilet transfers, and moving from lying to sitting on the side of the bed;
-Used manual wheelchair;
-Diagnoses included hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (one sided muscle weakness) following stroke affecting left-non-dominant side, generalized muscle weakness, sensorineural hearing loss (the inner ear nerve responsible for transmitting sounds are damaged), and metabolic encephalopathy (condition that can lead to personality changes).
Review of Resident #40's care plan, dated 10/10/22, showed:
-Be sure call light is within reach and encourage him/her to use it for assistance.
Observation on 2/5/24 at 2:01 P.M., showed the call light not in reach. Resident #32 had Resident #40's call light button.
2. Review of Resident #100's admission MDS, dated [DATE], showed:
-BIMS of 00, indicating undetermined cognitive status;
-Dependent for personal hygiene, dressing, bathing, toileting, oral hygiene;
-Required substantial/maximal assistance to roll left to right;
-Diagnoses included arthritis, osteoporosis (a condition causing bones to become weak and brittle), and pervasive developmental disorder (a condition characterized by delays in development of social and communication skills).
Review of the resident's care plan, dated 12/18/23, showed:
-Encourage the resident to use bell to call for assistance.
Observation on 2/5/24 at 2:20 P.M., showed the call light was laying on the floor along the wall under the call light plug and was not in reach while the resident lay in bed.
3. Review of Resident #9's annual MDS, dated [DATE], showed:
-BIMS of 14, indicating cognitively intact;
-Had impairment on one side on upper extremity and impairment to both sides on lower extremities;
-Required wheelchair for mobility;
-Was dependent for oral care, toileting, bathing, dressing, and mobility;
-Diagnoses included stroke (a condition resulting from damage to the brain from interruption of its blood supply), dementia (a group of thinking and social symptoms that interferes with daily functioning), traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), and contractures of joints.
Review of resident's care plan, dated 1/3/24, showed:
-Ensure call light is within reach.
Observation on 2/5/24 at 2:29 P.M., showed the call light was laying on the floor at the head of the bed and not in reach of the resident.
During an interview on 2/5/24 at 2:29 P.M., the resident said:
-He/She could not reach the call light.
4. Review of Resident #19's quarterly MDS, dated [DATE], showed:
-BIMS of 14, indicating cognitively intact;
-Dependent for toileting hygiene and lower body dressing;
-Required substantial/maximal assistance for bathing and mobility;
-Diagnoses included diabetes, urinary tract infection, generalized muscle weakness, rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in hands and feet), fibromyalgia (a long term condition that involves widespread body pain and tiredness), and lack of coordination.
During an interview on 2/5/24 at 2:31 P.M., the resident said:
-It sometimes took staff thirty minutes to answer his/her call light;
-Call light wait times had caused him/her to sit in wet briefs;
-Having to be incontinent of urine makes him/her feel neglected, uncomfortable, and itchy.
5. Review of Resident #7's quarterly MDS, dated [DATE], showed:
-BIMS of 15, indicating cognitively intact;
-Independent with toileting, personal hygiene, dressing, rolling left to right;
-Diagnoses included diabetes, low back pain, and opioid dependence (reliance on prescription pain medications).
Review of the resident's care plan, dated 1/3/24, showed:
-The resident has the right to be treated with consideration, respect, and dignity.
During an interview on 2/22/24 at 2:51 P.M., the resident said:
-Facility staff came into his/her room while he/she was not present and removed personal items off the top of his/her light and threw them on the bed;
-His/Her night table was turned so he/she could not access the drawers and was blocked by the edge of the bed;
-Facility staff told him/her to get rid of his/her stuff;
-Facility staff did not treat him/her like the facility was his/her home.
6. Review of Resident #58's quarterly MDS, dated [DATE], showed:
-BIMS of 15, indicating cognitively intact;
-Required substantial/maximal assistance with toileting hygiene, rolling left to right, and putting on and taking off footware;
-Required partial to moderate assistance with dressing his/her lower body;
-Diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), unsteadiness on feet, and generalized muscle weakness.
During an interview on 2/6/24 at 11:48 A.M., the resident said:
-The Social Services Director and Certified Nurse Aide (CNA) B came into the resident's room and moved his/her belongings while he/she was in the bathroom without his/her permission;
-His/Her personal items were placed in totes and items were removed from under the bed;
-He/She now cannot find personal stuff and some letters are missing;
-He/She felt frustrated that his/her personal items were gone through without his/her permission or being present.
7. During an interview on 2/6/24 at 12:01 P.M., CNA A said:
-The facility usually only has one aide working on the Maple and [NAME] halls;
-Call lights should be within a resident's arm reach or clipped to the resident;
-Resident #32 took Resident #40's call light stating he/she was tired of the staff's voice coming into room;
-He/She was aware that Resident #32 took the call light before 1:20 P.M. on 2/5/24;
-When he/she enters Resident #40's room, he/she will ensure the call light is back on the other resident's side of the room and within reach.
During an interview on 2/6/24 at 12:49 P.M., CMT A said:
-Call lights should be clipped to the bed or within reach such as being clipped to a resident's gown.
During an interview on 2/12/24 at 3:45 P.M., the Administrator said:
-Call lights should be answered in a reasonable time;
-Call lights should be within reach of the resident;
-Call lights should not be held and maintained by a resident's roommate, that is not appropriate.
-Residents have the right to their own personal belongings;
-When facility staff were going through and moving things off the top off closets we notified residents and offered totes so residents had a better way to store personal items;
-Facility staff talked to residents two to three days before completing deep cleaning;
-It is not appropriate to move a resident's belongings without the resident present or involved in the process.
MO230743
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to keep all areas of resident rooms clean, did not keep trash picked up off the floor, keep floors free of dirt and grime, remove used meal service dishes from rooms, empty trash in resident rooms, change dirty linens, and wipe down over bed tables, and properly clean soiled and stained furniture that was readily accessible to the residents of [NAME] hall and Maple hall. This affected eight (Resident #62, #18, #69, #35, #3, #40, #55, #31) of 20 sampled residents. The facility census was 82.
Review of the facility Residential Environmental Quality policy, dated 9/28/22 showed:
- It is the policy of the facility to be designed, constructed, equipped, and maintained to provide a safe,
functional, sanitary and comfortable environment for residents, staff, and the public.
Review of the facility Routine Cleaning and Disinfection policy, dated 9/1/21 showed:
- It is the policy of the facility to ensure the provision of routine cleaning and disinfection in order to
provide a safe, sanitary environment and to prevent the development and transmission of infections to
the extent possible;
- The policy defines cleaning as the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products.
1. Review of Resident #62's, significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/6/23 showed:
- Brief interview of metal status (BIMS) score of 5, which indicated severely impaired cognitive skills;
- The resident needed set up assistance for eating, oral hygiene, dressing, and siting to standing;
- The resident needed supervision for bathing and lower body dressing;
- The resident was independent for mobility and transfers.
Observation on 12/11/23 at 10:35 A.M. showed:
- A maroon colored chair located in the day room area between [NAME] hall and Maple hall;
- The seat of the chair littered with food crumbs and debris;
- Dark stains on the seat of the chair where the legs and groin area would commonly rest;
- Activities Assistant B pushed the maroon chair in under a nearby table without cleaning off the debris.
Observation on 12/11/23 at 11:45 A.M. showed:
- Activities Assistant A sitting in a chair in the day room area;
- The resident sitting in the maroon chair with stains and food debris still on the seat;
- The resident stood up from the maroon chair with food debris smashed onto his/her pants and onto the chair.
Observation on 12/14/23 at 5:25 A.M. showed:
- A recessed counter in the wall at the top of [NAME] hall;
- The counter was stacked with food trays and plates containing uneaten food;
- An order ticket with the trays showing the food was from the evening dinner meal served on 12/13/23.
During an interview on 12/14/23 at 1:09 P.M., Certified Nurses Aide (CNA) I said:
- Furniture should be free of stains and food debris;
- Any staff that see a mess should clean it;
- Completed or partially completed meal trays should be taken back to the kitchen;
- Trays with leftover food should not be left in the resident halls overnight.
During an interview on 12/14/23 at 1:21 P.M., Licensed Practical Nurse (LPN) G said:
- Furniture should be free of stains and food debris;
- Any staff that see a mess should clean it;
- Completed or partially completed food trays should go back in meal cart or back to kitchen;
- Food should not be left in the hall overnight.
During an interview on 12/14/23 at 1:40 P.M., Housekeeper B said:
- He/She would expect the furniture in the facility to be clear of food debris and not stained;
- All staff should notify housekeeping if furniture is stained;
- All staff would be expected to clean up food debris if it was observed;
- CNA's and nursing staff take meal trays back to kitchen once residents are done with them;
- Housekeeping staff would help with meal trays if asked.
During an interview on 12/14/23 at 2:08 P.M., Housekeeper A said:
- He/She would expect the furniture in the facility to be clear of food debris and not stained;
- All staff should notify housekeeping if furniture is stained;
- All staff would be expected to clean up food debris if it was observed;
- Housekeeping does not handle food trays unless asked.
2. Review of Resident #18's, annual MDS, dated [DATE] showed:
-BIMS score of 15, which indicated resident was cognitively intact;
-The resident required supervision or touching assistance when eating, oral hygiene, and personal hygiene;
-The resident was dependent for bathing;
-The resident required set up or clean up assistance for toileting and dressing;
-Diagnoses included acute respiratory failure with hypoxia (a condition where there is not enough oxygen in tissues in the body), need for assistance with personal care, hearing loss, and chronic pain syndrome.
Observation on 12/11/23 at 10:42 A.M. showed wrappers on floor of resident room, trash can was full of trash.
During an interview on 12/11/23 at 10:42 A.M., the resident said housekeeping did not clean his/her room yesterday.
3. Review of Resident #69's, quarterly MDS, dated [DATE], showed:
-BIMS score of 15, which indicated resident was cognitively intact;
-The resident was independent with toileting, eating, dressing, transfers, and personal hygiene;
-The resident required set up or clean up assistance for bathing;
-Diagnoses included diabetes (a condition causing too much sugar in the blood), adjustment disorder (excessive reactions to stress that involved negative thoughts, strong emotions, and changes in behavior), and depression.
Observation on 12/11/23 at 10:35 A.M. showed stained sheets on the bed, gallon of milk hidden under the bed with only 1/8th of container let and the floor had piles of dirt and clumps of mud.
4. Review of Resident #35's quarterly MDS, dated [DATE], showed:
-BIMS score of 15, which indicated resident had cognitively intact;
-Supervised or touching assistance for toileting and upper body dressing;
-Independent with rolling, sitting to lying, lying to sitting on side to bed, chair to bed transfers, and toilet transfers;
-Diagnoses included generalized muscle weakness, difficulty in walking, dementia (a group of thinking and social symptoms that interferes with daily functioning characterized by impairment of at least two brain functions), and chronic pain syndrome.
Observation on 12/11/23 a 12:31 P.M. showed the trash can in the room was full of trash, rings on top of the night stand from drinks, and sticky sugar on the over the bedside table
During an interview on 12/11/23 at 12:31 P.M., the resident said the facility had no weekend housekeeping.
5. Review of Resident #3's quarterly MDS, dated [DATE], showed:
-BIMS score of 15, which indicated resident was cognitively intact;
-The resident required set up or clean up assistance for eating, oral hygiene, and personal hygiene;
-The resident was independent with toileting hygiene, upper body dressing, and mobility;
-The resident required partial to moderate assistance with bathing;
-Diagnoses included diabetes , stroke (damage to the brain from the interruption of blood supply), depression, history of falling, cognitive communication deficit, and mild mental retardation.
Observation on 12/11/23 at 11:35 A.M., showed the resident's floor had piles of mud and dirt streaked across it.
6. Review of Resident #40's annual MDS, dated [DATE], showed:
-BIMS score of 10, indicated the resident had moderately impaired cognition;
-The resident required substantial or maximal assistance with shower and bathing self, lower body dressing, sitting to standing mobility, chair to bed transfers;
-The resident required partial or moderate assistance with toileting hygiene, toilet transfers, and moving from lying to sitting on the side of the bed;
-Diagnoses included hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (one sided muscle weakness) following stroke affecting left-non-dominant side, generalized muscle weakness, sensorineural hearing loss (the inner ear nerve responsible for transmitting sounds are damaged), and metabolic encephalopathy (condition that can lead to personality changes).
Observation on 12/11/23 at 11:36 A.M., showed his/her bed sheets with caked on food. The bed side table had food caked on it. The floor in front of the bed had sticky substance and dirt . The resident's wheelchair had sticky substances over the sides and handles.
7. Review of Resident #55's quarterly MDS, dated [DATE], showed:
-BIMS score of 10, indicated the resident had moderately impaired cognition;
-The resident required substantial to maximal assistance with toileting hygiene, lower body dressing, chair to bed transfers, and shower transfers;
-The resident required partial to moderate assistance with upper body dressing, sitting to lying mobility, and lying to sitting mobility;
-The resident was dependent for bathing;
-The resident was independent with eating;
-Diagnoses included dementia, depression, anxiety, difficulty in walking, and unsteadiness on feet.
Observation on 12/11/23 at 11:56 A.M. showed a strong odor of feces coming from the resident's room. Dirty clothes and a bag with feces in it was on the floor.
Observation on 12/11/23 at 2:58 P.M., showed strong odor of urine in the resident's room. Toilet paper and sugar packets were on the floor.
8. Review of Resident #31's MDS, dated [DATE], showed:
-BIMS of 13, the resident is cognitively intact;
-The resident required set up or clean up assistance with eating, oral hygiene, toileting, and transitioning from sitting to standing positions;
-The resident required supervision or touching assistance with dressing, and personal hygiene.
-The resident required partial/moderate assistance with bathing;
-The resident was independent with mobility of sitting to lying, chair to bed transfer, toilet transfers, and rolling;
-Diagnoses included: Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia, and need for assistance with personal care.
9. Observation on 12/11/23 at 9:54 A.M. showed a soiled linen container in the hallway with dirty dishes stacked up on top.
Observation on 12/11/23 at 2:59 P.M. showed the resident's bed sheets were stained brown, floor had piles of mud and dirt scattered across floor.
Observation on 12/14/23 at 5:24 A.M. showed on Maple hall were stacks of dirty dishes on the treatment cart. Dirty dishes were observed in the window well ledge by room [ROOM NUMBER]-A.
During an interview on 12/13/23 at 6:21 A.M., CNA D said:
-He/She collected the dishes during his/her shift and took to the kitchen;
During an interview on 12/14/23 at 4:51 P.M., Dietary Manager said:
-Nursing staff's responsibility to return dirty dishes to kitchen
-When he/she arrived in morning there were dishes piled up on table in dining room;
-There are often dirty dishes piled up on each unit hallways cubbies by resident rooms and in the hall kitchettes.
During an interview on 12/14/23 at 5:22 P.M., the Director of Nursing said:
-He/She expected facility to be clean and safe;
-The whole team was responsible for gathering and taking dirty dishes to the kitchen after meals.
During an interview on 12/14/23 at 5:22 P.M., the Administrator said:
- He/She expected all resident room and the facility to be clean and homelike.
-He/She expected the facility to be clean.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure that the criminal background check (CBC) of three out of six sampled nursing staff employees was completed, when the facility did n...
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Based on record review and interviews, the facility failed to ensure that the criminal background check (CBC) of three out of six sampled nursing staff employees was completed, when the facility did not provide in the employee HR (Human Resource) file that the facility had completed a criminal back ground check through the Missouri State Highway Patrol (MSHP) prior to allowing resident contact, nor did they retain any documentation supporting that it had been completed by the facility. The facility census was 82.
Review of the Missouri State Statute Chapter 192.2495 dated 8/28/18 showed:
Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider:
(1) Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose of conducting an employee criminal records background check shall be deemed to fulfill the provider's duty to conduct employee criminal background checks pursuant to this section; except that, completing the inquiries pursuant to this subsection shall not be construed to exempt a provider from further inquiry pursuant to common law requirements governing due diligence. If an applicant has not resided in this state for five consecutive years prior to the date of his or her application for employment, the provider shall request a nationwide check for the purpose of determining if the applicant has a prior criminal history in other states. The fingerprint cards and any required fees shall be sent to the highway patrol's central repository. The fingerprints shall be used for searching the state repository of criminal history information. If no identification is made, fingerprints shall be forwarded to the Federal Bureau of Investigation for the searching of the federal criminal history files. The patrol shall notify the submitting state agency of any criminal history information or lack of criminal history information discovered on the individual. The provisions relating to applicants for employment who have not resided in this state for five consecutive years shall apply only to persons who have no employment history with a licensed Missouri facility during that five-year period. Notwithstanding the provisions of section 610.120, all records related to any criminal history information discovered shall be accessible and available to the provider making the record request.
Review of the undated Pre-Employment checks policy showed:
- The CBC was to be completed through the Family Care Safety Registry (FCSR) prior to being hired.
- Check the Employee Disqualification Lift (EDL) prior to hire and quarterly.
- Office of Inspector General (OIG) check to be completed prior to hire and yearly by 6/1.
- If an employee listed an out of state address, the CNA registry and CBC were to be completed for those states.
1. Review of MDS (Minimum Data Set) personnel records showed:
- Date of Hire (2/16/22)
-No documentation indicating a Criminal Background Check (CBC) was completed.
2. Review of LPN C's personnel record showed:
- Date of Hire (9/20/22)
- No documentation indicating a Criminal Background Check was completed.
3. Review of former employee A's personnel record showed:
- Date of Hire ( 9/22/23)
-No documentation indicating a Criminal Background Check was completed.
Interview on 12/14/23 at 4:00 P.M. the Administrator said:
- She expected a CBC to be completed on each staff member prior to hire.
- She expected the CBC to be available in the employee folder.
- The facility was not following policy by not completing a CBC for employee (MDS coordinator, LPN C and a former employee A.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents(Resident #8, and #15) who had a diagnosis of b...
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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 two residents(Resident #8, and #15) who had a diagnosis of bipolar disorder and unspecified psychosis ( both are a serious mental disorder in which people interpret reality abnormally) had a Preadmission Screening and Resident Review (PASARR) completed and reviewed by the facility as part of the resident's admission into the facility. The facility census was 82.
The facility did not provide a policy for PASARR.
2. Review of Resident #15's quartley Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/26/23., showed:
- A brief interview of mental status (BIMS) score of 11, indicating moderate cognitive impairment.
- Showed resident received cognitive-enhancing medications for dementia (a condition in which the brain function is impaired and affects reasoning and memory) and bi-polar treatment ( A psychiatric illness characterized by both hyper and depressive episodes of behavior).
- Resident required one person physical assist for bathing and personal hygiene oversight for safety.
Review of resident's electronic medical record (EMR) showed:
-No PASARR was identified in the EMR from admission date of 4/2/21 thru 12/14/23.
During an interview on 12/14/23 at 8:30 A.M., the Social Service Director said:
-She was unable to produce the PASARR.
During an interview on 12/14/23 at 1:15 P.M., the Administrator said:
-The Social Services Director is responsible for initiating all PASARR's that are not present on admission, and are followed up for completion by the MDS coordinator.
During an observation on 12/14/23 at 4:03 P.M., a copy of the resident's PASARR was obtained from Central Office Medical Review Unit (COMRU), and showed:
-The PASARR was outdated and should have been completed with admission to facility.
2. Review of Resident # 8's Quarterly MDS, dated [DATE] showed:
- An admission date of 4/21/22
- A BIMS score of 15, indicating no cognitive impairment;
- Staff made no indication if the resident had been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition;
- No indication on whether or not the resident had a serious mental illness, mental retardation or other related condition;
- A resident mood interview should be conducted;
- No indication of a resident mood interview being conducted;
- Diagnoses included anxiety disorder, depression, manic depression (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration).
Review of the resident's undated face sheet showed in part:
- Diagnoses of unspecified anxiety disorder, recurrent major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), and generalized anxiety disorder (a mental health condition that causes constant and uncontrolled worrying)
Review of the resident's care plan, dated 12/12/23 showed:
- The resident had been identified as having potential for PASRR positive status related to severe mental illness of bipolar disorder and anxiety;
- An instance where the resident rammed his/her wheelchair into another resident;
- An intervention for staff to intervene if the resident becomes agitated;
- The resident uses antidepressant medication related to depression and bipolar disorder;
- The resident uses anti-anxiety medications related to anxiety;
- The resident uses psychotropic medications related to bipolar disorder.
Review of the resident's electronic medical record (EMR) on 12/14/23, showed no evidence of completion of the Level I or Level II PASRR form.
The facility was unable to provide any documentation related to the completion of the Level I or Level II PASRR form for Resident # 8.
During an observation on 12/14/23 at 4:03 P.M., a copy of the resident's PASARR was obtained from Central Office Medical Review Unit (COMRU), and showed:
-The PASARR was outdated and should have been completed with admission to facility.
During an interview on 12/14/23 at 5:00 P.M., the Administrator said:
-She knew the facility did not have a copy of the PASARR and a new one would need to be completed;
-It was her expectation that all residents will have a PASARR completed at admission if not prior to;
-She was not aware that PASARR's were incomplete.
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 #25's quarterly MDS, dated [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #25's quarterly MDS, dated [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The resident required setup assistance for eating and oral hygiene;
- The resident was dependent on staff for toileting, hygiene, rolling, bathing, and transfers;
- Diagnoses of heart failure, renal insufficiency (kidneys do not work properly), diabetes (a condition in which the body does not process blood sugar properly), hyperlipidemia (high cholesterol), anxiety, depression, severe obesity, and asthma.
Review of the resident's active physicians order sheet, dated 12/14/23 showed:
- An order to check blood sugars before meals, hour of sleep, and as needed:
- Glucometer high/low reading and cleaning every Friday night shift;
- Insulin Aspart injection per sliding scale if 201-250 = 2 units, 251-300 = 5 units, 301-350= 8 unit, 351-400= 12 units, given subcutaneously before meals for diabetes;
- Insulin Demtemir solution 100 unit/ml inject 15 unit subcutaneously in morning for diabetes;
- Insulin Demtemir solution 100 unit/ml inject 52 unit subcutaneously at bedtime for diabetes;
- Novolog Flexpen subcutaneous solution 100 unit/ml, inject 10 units subcutaneously before meals for diabetes and give 10 unites before meals with sliding scale.
Review of the resident's care plan, revised 10/24/23 showed:
- The resident had type two diabetes;
- Diabetes medications should be administered as ordered by doctor;
- Accu-checks (checking the bloodsugar) before meals and at bedtime.
Review of the resident's medication and treatment administration records for 12/1/23 to 12/13/23 showed:
- The order for glucometer high/low reading and cleaning every Friday night shift was not completed on 12/8/23;
- The order for insulin Demtemir solution 100 unit/ml inject 15 unit subcutaneously in morning for diabetes was not completed on 12/8/23 and 12/10/23;
- The order for insulin Demtemir solution 100 unit/ml inject 52 unit subcutaneously at bedtime for diabetes was not completed on 12/10/23;
- The orders for insulin Aspart injection per sliding scale if 201-250 = 2 units, 251-300 = 5 units, 301-350= 8 unit, 351-400= 12 units, given subcutaneously before meals for diabetes and Novolog Flexpen subcutaneous solution 100 unit/ml, inject 10 units subcutaneously before meals for diabetes and give 10 unites before meals with sliding scale were not completed on the midday meals on 12/8/23 and 12/10/23 and evening meals on 12/10/23 and 12/11/23;
- The order to check blood sugars before meals, hour of sleep, and as needed was not completed before the morning meal on 12/8/23, no blood sugar checks on all three meals on 12/10/23, and no check before the midday meal on 12/11/23.
During an interview on 12/13/23 at 9:11 AM, Resident #25 said:
- He/She had not gotten his/her morning insulin;
- The insulin should be administered before breakfast;
- Breakfast had already been served;
- He/She needed insulin because he/she commonly had high blood sugars.
During observation and interview on 12/14/23 showed:
- The resident did not receive insulin with morning med pass prior to him/her eating breakfast at 8:31 A.M.;
-The resident's blood sugars were not checked prior to him/her eating breakfast at 8:31 A.M.
During an interview on 12/14/23 at 12:34 P.M., CMT C said:
- Physicians orders should be followed;
- Orders that give directions for the treatment or medication to be administered before or after meals should be followed.
During an interview on 12/14/23 at 1:21 P.M., LPN G said:
- Insulin and blood sugar checks should be administered per physician's orders;
- The resident's orders for insulin and accu-checks before meals should have been administered before he/she ate.
1. Review of Resident #45's significant change minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/31/23, showed:
-Resident was cognitively intact;
-Required partial to moderate assistance with showers, toileting hygiene, and tub or shower transfers;
-Utilized motorized wheelchair;
-Diagnoses included congestive heart failure, lymphedema (condition that causes swelling in an arm or leg caused by a lymphatic system blockage), atherosclerosis (the build up of fats, cholesterol, and other substances in and on the artery walls) of native arteries of right lag with ulceration (painful sore), right lower leg ulcer, obesity, and generalized muscle weakness.
Review of care plan, dated 10/5/23, showed:
-Give cardiac medications as ordered;
-Monitor vital signs. Notify medical doctor (MD) of significant abnormalities;
-Administer medications as ordered. Monitor/document for side effects and effectiveness.
During an interview on 12/11/23 at 3:16 P.M., resident said:
-He/She was supposed to have wound dressings changed daily and that was not occurring as ordered by facility staff.
During an observation on 12/11/23 at 3:45 P.M., showed dressing was undated, saturated in a dark yellow.
Review of Medication Administration Records (MARS), dated 10/1/23 to 10/31/23, showed:
-Aspirin tablet chewable 81mg (give 1 tablet by mouth one time a day for afibrilation) with start date of 10/6/23, showed no documentation was entered:
-8:00 A.M. on 10/19, 10/20, 10/23, and 10/24;
-Metoprolol succinate ER tablet extended release 24 hour 50 milligram (mg), (give 1 tablet by mouth one time a day for hypertension. Hold if systolic blood pressure greater than 110 and pulse below 60), started 10/6/23, had no documentation entered:
-8:00 A.M. on 10/19, 10/20, 10/23, and 10/24;
-Potassium Chloride ER tablet extended release 20 milliequivalent (mEq), give 2 tablet by mouth two times a day for supplement), start date of 10/5/23, had no documentation entered:
-8:00 A.M. had no documented administration entry for 10/19, 10/20, 10/23, and 10/24.
-8:00 P.M. on 10/18, 10/19, 10/20, 10/21, 10/22, and 10/23;
-Sennosides tablet 8.6 mg, give 1 tablet by mouth two times a day for constipation, started 10/5/23 at 8:00 A.M. and 8:00 P.M. had no documentation entered for:
-8:00 A.M. on 10/19, 10/20, 10/23, and 10/24;
-8:00 P.M. on 10/18, 10/19, 10/20, 10/21, 10/22, and 10/23;
-Spironalactone tablet 25 mg, give 1 tablet by mouth two times a day for hypertension, started 10/5/23 at 8:00 A.M and 8:00 P.M. had no documentation entered for:
-8:00 A.M. on 10/19, 10/20, 10/23, and 10/24;
-8:00 P.M. on 10/18, 10/19, 10/20, 10/21, 10/22, and 10/23;
-Torsemide tablet 100 mg, give 1 tablet by mouth two times a day for edema, started 10/11/23 at 8:00 A.M. and 3:00 P.M., had no documentation entered for:
-8:00 A.M. on 10/19, 10/20, 10/23, and 10/24;
-3:00 P.M. on 10/19, 10/20, and 10/23;
-No vital signs documented on 10/6/23.
Review of MARS, dated 11/1/23 to 11/30/23, showed:
-Atorvastatin calcium oral tablet 40 mg, give 1 tablet at bedtime for hyperlipidemia, started 10/24/23, had no documentation entered:
-8:00 P.M. on 11/1 and 11/6;
-Metoprolol succinate ER tablet extended release 24 hour 50mg, give 1 tablet by mouth one time a day for hypertension. Hold if systolic blood pressure greater than 110 and pulse below 60, started 10/6/23, had no documentation entered:
-8:00 A.M. on 11/5;
-Eliquis oral tablet 5mg, give 5mg by mouth two times a day for prophylaxis related to paroxysmal atrial fibrillation, started on 10/24/23, had no documentation entered:
-8:00 P.M. on 11/1 and 11/6;
-Potassium Chloride ER tablet extended release 20 mEq, give 2 tablet by mouth two times a day for supplement, started on 10/5/23, had no documentation entered:
-8:00 P.M. on 11/1 and 11/6;
-Sennosides tablet 8.6 mg, give 1 tablet by mouth two times a day for constipation, started 10/5/23, had no documentation entered for:
-8:00 P.M. on 11/1 and 11/6;
-Spironalactone tablet 25 mg , give 1 tablet by mouth two times a day for hypertension, started 10/5/23, had no documentation entered for:
-8:00 P.M. on 11/1 and 11/6.
Review of MARS, dated 12/1/23 to 12/13/23, showed:
-Atorvastatin calcium oral tablet 40 mg, give 40mg by mouth at bedtime for hyperlipedemia, started 10/24/23 at 8:00 P.M. showed no documentation was entered:
-8:00 P.M. on 12/1;
-Eliquis oral tablet 5mg, give 5mg by mouth two times a day for prophylaxis related to paroxysmal atrial fibrillation, started on 10/24/23, had no documentation entered:
-8:00 P.M. on 12/1;
-Metamucil powder, give 1 teaspoon by mouth two times a day for constipation mix 1 tsp with 8 ounces (oz) of water, started on 11/10/23, showed no documentation was entered:
-8:00 P.M. on 12/1;
-Potassium chloride ER tablet extended release 20 mEq, give 2 tablet by mouth two times a day for supplement, started10/5/23, had no documentation entered:
-8:00 P.M. on 12/1;
-Sennosides tablet 8.6 mg, give 1 tablet by mouth two times a day for constipation, started 10/5/23, had no documentation entered for:
-8:00 P.M. on 12/1;
-Spironalactone tablet 25 mg, give 1 tablet by mouth two times a day for hypertension, started 10/5/23, had no documentation entered for:
-8:00 P.M. on 12/1.
Review of Treatment Administration Record (TARS), dated 10/1/23 to 10/31/23, showed:
-Ammomium lactate solution, applied to affected areas topically every day shift for dry skin,, started 10/12/23, had no documentation entered for:
-Day shift 10/23 and 10/24;
-Cleanse bilateral lower extremity (BLE) with wound cleanser apply aquacel to open areas BLE, cover with army battle dressing (ABDs), wrap with gauze dressings, change daily and prn when saturated one time a day for wounds, started 10/6/23, had no documentation entered on 10/8, 10/9, and 10/11;
-Cleanse open area to outer aspect of right foot with wound cleanser; apply medihoney to wound and cover with dry dressing, change daily and prn for soiling every day shift, started 10/12/23, had no documentation entered for 10/14, 10/23, and 10/24.
Review of TARS, dated 11/1/23 to 11/30/23, showed:
-Ammomium Lactate Solution (Apply to affected areas topically every day shift for dry skin, started 10/12/23, had no documentation entered for the day shift 11/5, 11/6, and 11/13;
-Cleanse BLE with wound cleanser, apply absorbent pads to weeping areas and wrap BLE with kerlix; change daily or prn for soiling every day shift for wounds/skin care, started 11/10/23 had no documentation entered for 11/13;
-Cleanse open area to outer aspect of right foot with wound cleanser; apply medihoney to wound and cover with dry dressing; change daily and prn for soiling every day shift for wound, started 10/12/23, had no documentation entered for the day shift on 11/5, 11/6, and 11/13;
-Doxycycline hyclate tablet 100mg, give 1 tablet by mouth for infection for seven days, started 11/2/23, had no documentation entered on 11/5.
Review of TARS, dated 12/1/23 to 12/13/23, showed:
-Cleanse BLE with wound cleanser, apply absorbent pads to weeping areas and wrap BLE with kerlix; change daily or prn for soiling every day shift for wounds/skin care, started 11/10/23 had no documentation entered for 12/10/23;
-Cleanse open area to outer aspect of right foot with wound cleanser, apply medihoney to wound and cover with dry dressing; change daily and prn for soiling every day shift for wound, started 10/12/23, had no documentation entered for 12/10/23.
Review of electronic medical record (EMR), dated December 2023, showed:
-12/8/23 at 11:03 A.M. resident refused BLE dressing change due to having dressings changed at lymphedemia clinic. Nurse explained appointment had been rescheduled for 12/11/23. Resident still refused to allow nurse to change dressings.
-12/8/23 at 11:57 A.M. social services director and director of nursing (DON) explained to resident importance of allowing nurse to change wraps. DON provided resident proof that dressing changes were to be completed daily. Resident allowed nurse to change his dressings. Wound to right lateral leg as noted foul odor with thick yellow drainage. Area also noted to have large amount of slough. Resident remained on antibioitc for treatment of infected wounds.
2. Review of Resident #35's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/13/23 showed:
-Intact cognition;
-Supervised or assistance for toileting and upper body dressing;
-Independent with rolling, sitting to lying, lying to sitting on side to bed, chair to bed transfers, and toilet transfers;
-Used a manual wheelchair;
-Diagnoses included osteoarthritis of right hip (a degenerative disease that worsens over time resulting in chronic pain), polyneuropathy (many nerves in different parts of the body causing weakness, numbness, and pain from nerve damage), intervertebral disc degeneration of lumbar region (loss of cushioning, fragmentation, and herniation related to aging), generalized muscle weakness, difficulty in walking, dementia (a group of thinking and social symptoms that interferes with daily functioning characterized by impairment of at least two brain functions), and chronic pain syndrome.
Review of care plan, dated 9/21/23, showed:
-Provide medications as ordered;
-Notify physician of medication refusals or missed doses.
During an interview on 12/11/23 at 12:31 P.M., the resident said he/she was not getting adequate care because she was not getting medications as prescribed by her physician.
Review of MARS dated 10/1/23 to 10/31/23, showed:
-Calcium 600+D3 tablet 600-400 mg-unit, give 1 tablet by mouth two times a day for supplement, started 10/4/21, showed no documentation had been entered:
-8:00 A.M. on 10/1 and 10/2;
-5:00 P.M. on 10/1 and 10/2;
-Celecoxib capsule 100 mg, give 1 capsule by mouth two times a day for inflammation, started 9/28/22, showed no documentation was entered:
-8:00 A.M. on 10/1 and 10/2;
-8:00 P.M. on 10/1 and 10/2;
-Famotidine tablet 20 mg, give 1 tablet by mouth two times a day for acid indigestion take two 10mg tabs to equal 10 mg dose, started 10/4/21, showed no documentation was entered:
-8:00 A.M. on 10/1 and 10/2;
-8:00 P.M. on 10/1 and 10/2;
-Senna-S tablet 8.6-50 mg, give 2 tablet by mouth two times a day for constipation, started 4/4/23, showed no documentation was entered:
-8:00 A.M. on 10/1 and 10/2;
-8:00 P.M. on 10/1 and 10/2;
-Buspirone HCl tablet 15 mg, give 1 tablet by mouth four times a day for anxiety, started 9/24/23, showed no documentation was entered:
-8:00 A.M. on 10/1 and 10/2;
-12:00 P.M. on 10/1 and 10/2;
-4:00 P.M. on 10/1 and 10/2;
-8:00 P.M. on 10/1 and 10/2;
-Gabapentin tablet 600 mg, give 1 tablet by mouth four times a day related to unspecified dementia, severe agitation, bipolar, major depressive disorder, generalized anxiety, started 7/17/23, showed no documentation was entered:
-8:00 A.M. on 10/1 and 10/2;
-12:00 P.M. on 10/1 and 10/2;
-4:00 P.M. on 10/1 and 10/2;
-8:00 P.M. on 10/1 and 10/2;
Review of MARS, dated from 11/1/23 to 11/30/23, showed:
-Cetirizine HCl tablet 10 mg, give 1 tablet by mouth at bedtime for allergy symptoms, started 6/5/23, showed no documentation was entered:
-8:00 P.M. on 11/6;
-Cholecalciferol tablet 5000 unit, give1 tablet by mouth one time a day for vitamin, started 10/5/21, showed no documentation was entered:
-12:00 P.M. on 11/5;
-Simvastatin tablet 40 mg, give 1 tablet by mouth at bedtime for high cholesterol, started 10/4/21, showed no documentation was entered:
-8:00 P.M. on 11/6;
-Trazodone Hcl tablet 100 mg, give 200 mg by mouth at bedtime related to bipolar disorder and unspecified major depressive disorder, started on 10/25/22, showed no documentation was entered:
-8:00 P.M. on 11/6;
-Celecoxib capsule 100 mg, give 1 capsule by mouth two times a day for inflammation, started 9/28/22, showed no documentation was entered:
-8:00 P.M. on 11/6;
-Famotidine tablet 20 mg, give 1 tablet by mouth two times a day for acid indigestion take two 10mg tabs to equal 10 mg dose, started 10/4/21, showed no documentation was entered:
-8:00 P.M. on 11/6;
-Senna-S tablet 8.6-50mg, give 2 tablet by mouth two times a day for constipation, started 4/4/23, showed no documentation was entered:
-8:00 P.M. on 11/6;
-Gabapentin tablet 600 mg, give 1 tablet by mouth four times a day related to unspecified dementia, severe agitation, bipolar, major depressive disorder, generalized anxiety, started 7/17/23, showed no documentation was entered:
-12:00 P.M. on 11/5;
-8:00 P.M. on 11/6.
Review of MARS dated 12/1/23 to 12/13/23, showed:
-Cetirizine HCl tablet 10 mg, give 1 tablet by mouth at bedtime for allergy symptoms, started 6/5/23, showed no documentation was entered:
-8:00 P.M. on 12/1;
-Melatonin tablet 5mg, give 2 tablet by mouth at bedtime for insomnia, started 12/1/23, showed no documentation was entered:
-8:00 P.M. on 12/1;
-Simvastatin tablet 40 mg, give 1 tablet by mouth at bedtime for high cholesterol, started 10/4/21, showed no documentation was entered:
-8:00 P.M. on 12/1;
-Trazodone Hcl tablet 100 mg, give 200 mg by mouth at bedtime related to bipolar disorder, unspecified major depressive disorder), started on 10/25/22, showed no documentation was entered:
-8:00 P.M. on 12/1;
-Acidophilius capsule, give 1 capsule by mouth two times a day for prophylaxis, started 11/9/23, showed no documentation was entered:
-8:00 P.M. on 12/1;
-Celecoxib capsule 100 mg, give 1 capsule by mouth two times a day for inflammation, started 9/28/22, showed no documentation was entered
-8:00 P.M. on 12/1;
-Famotidine tablet 20 mg, give 1 tablet by mouth two times a day for acid indigestion take 2 10mg tabs to equal 10 mg dose, started 10/4/21, showed no documentation was entered:
-8:00 P.M. on 12/1;
-Senna-S tablet 8.6-50 mg, give 2 tablet by mouth two times a day for constipation, started 4/4/23, showed no documentation was entered:
-8:00 P.M. on 12/1;
-Gabapentin tablet 600 mg, give 1 tablet by mouth four times a day related to unspecified dementia, severe agitation, bipolar, major depressive disorder, and generalized anxiety, started 7/17/23, showed no documentation was entered:
-8:00 P.M. on 12/1.
Review of TARS, dated 10/1/23 to 10/31/23, showed:
-Ted hose applied in morning, started 10/5/22, showed no documentation was entered 10/1, 10/2, and 10/8.
-Aspercreme lidocaine patch 4%, apply to lower back topically one time a day for pain, showed no documentation was entered:
-6:00 A.M. on 10/1, 10/2, 10/15, and 10/21;
-6:00 P.M. on 10/1 and 10/2;
-Levothyroxine sodium tablet 25 mcg, give 1 tablet by mouth one time a day for Parkinsons disease, started 10/5/21, showed no documentation was entered:
-6:00 A.M. on 10/1, 10/2, 10/3, and 10/15;
-Remove [NAME] hose at hour of sleep (HS) started 10/4/22, showed no documentation was entered on 10/1 and 10/2.
Review of TARS, dated 11/1/23 to 11/30/23, showed:
-Ted hose applied in morning, started 10/5/22, showed no documentation was entered 11/5;
-Aspercreme lidocaine patch 4%, apply to lower back topically one time a day for pain, showed no documentation was entered:
-6:00 A.M. on 11/1;
-6:00 P.M. on 11/5;
-Levothyroxine sodium tablet 25 mcg, give 1 tablet by mouth one time a day for Parkinsons disease, started 10/5/21, showed no documentation was entered:
-6:00 A.M. on 11/1;
-Remove [NAME] hose at HS, started 10/4/22, showed no documentation was entered on 11/21;
Review of TARS, dated 11/1/23 to 11/30/23, showed:
-Aspercreme lidocaine patch 4%, apply to lower back topically one time a day for pain, showed no documentation was entered:
-6:00 A.M. on 12/6;
-Levothyroxine sodium tablet 25 mcg, give 1 tablet by mouth one time a day for Parkinsons disease, started 10/5/21, showed no documentation was entered:
-6:00 A.M. on 12/6;
During an interview on 12/14/23 at 5:17 P.M., Certified Medication Technician (CMT) A said:
-If the MAR showed a medication was not signed for it meant the medication was not administered;
-When resident refuses medication the electronic medical record goes through process where they mark refusal and are required to put in a resident refused progress note;
-When missing medication he/she would check the medication box, if medication was not available on site he/she would notify the pharmacy and order medications;
-It was not acceptable to leave a spot on MAR blank, an identifier should be used.
During an interview on 12/14/23 at 4:43 P.M., the DON said:
-He/She was aware that there are some issues with medication passes.
-He/She had not done recent reviews of medication passes;
-When there are blanks on the MAR the nurse should notify the physician and management should also be notified;
-She expects staff to report medication errors via a risk management report with as much information as possible;
- She expects treatments to be completed per the physician's order.
Based on observation, record review and interviews, the facility failed to provide care and treatment in accordance with professional standards of practice when licensed nursing staff failed to ensure that physician orders were carried out correctly for Residents #25, #35, and #45. This affected three out of the 18 sampled residents directly for medication administration,The facility census was 82.
The facility did not provide a policy on documentation of mediation administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 staff failed to provide bathing assistance and document showers...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to provide bathing assistance and document showers for three of the 18 sampled dependent residents (Resident #40, #55, and #3). The facility census was 82.
The facility did not provide a policy on activities of daily living (ADL's).
1. Review of Resident #40's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/26/23 showed:
-Moderately impaired cognition;
-Required substantial or maximal assistance with shower and bathing self, lower body dressing, sitting to standing mobility, chair to bed transfers;
-Used a manual wheelchair for mobility;
-Diagnoses included: Hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (one sided muscle weakness) following a stroke and affecting left-non-dominant side, generalized muscle weakness, sensorineural hearing loss (the inner ear nerve responsible for transmitting sounds are damaged), metabolic encephalopathy (condition that can lead to personality changes).
Review of resident's care plan, dated 12/11/23, showed:
-Resident preferred showers in the afternoon;
-He/She prefers to bathe twice weekly;
-He/She refused showers and shave frequently, resident will be encouraged but allowed to refuse care per fights;
-Residents hair should be washed during baths;
-Keep fingernails short.
-Change clothes and briefs as needed;
During an observation on 12/11/23 at 11:37 A.M. showed the resident's nails long with brown stuff underneath. Resident was wearing a hospital gown with food caked on it.
During an observation on 12/13/23 at 6:18 A.M. showed the resident, wearing a stained sweatshirt and had red sticky substance in his/her hair and his/her hair was disheveled.
Review of shower schedule showed staff are to provide the reisdent with a shower on the evening shift on Mondays and Thursdays.
Review of facility provided shower logs and electronic bathing record, 9/28/23 to 12/14/23, showed
-9/28/23 resident refused shower and shave and toenails needed cut;
-10/5/23 resident received shower, nails cut, and was shaved;
-11/30/23 resident received shower
-Three showers were offered out of twenty-six opportunities.
During an interview on 12/12/23 at 7:45 A.M., CNA F said he/she had never given the resident a shower during his/her shift due to the resident not being scheduled for showers on his/her working days. When a resident needs a shower staff should assist with reisdent with getting one.
2. Review of Resident #55's quarterly MDS, dated [DATE], showed:
-BIMS (Brief Interview for Mental Status) score of 10, indicated the resident had moderately impaired cognition;
-The resident required substantial to maximal assistance with toileting hygiene, lower body dressing, chair to bed transfers, and shower transfers;
-The resident required partial to moderate assistance with upper body dressing, sitting to lying mobility, and lying to sitting mobility;
-The resident was dependent for bathing;
-Diagnoses included dementia (a condition causing group of thinking and social symptoms that interferes with daily functioning), depression, anxiety, difficulty in walking, and unsteadiness on feet.
Review of the reisdent's care plan, dated 8/30/23, showed:
-Adjust assistance provided as needed depending on residents level of fatigue and cue as needed due to cognitive impairment;
-Resident required limited assistance by one staff with showering twice weekly and as necessary;
-Resident required staff to dress. Resident needed more assistance with lower body dressing due to balance problems;
-Resident required set up assistance with personal hygiene and oral care.
Observation on 12/11/23 at 11:56 A.M., showed a strong odor of feces in resident's room. The resident was observed sitting in his/her wheelchair, half dressed and attempting to pull his/her pants up.
Observation on 12/11/23 at 2:58 P.M. showed the resident's hair was disheveled and had flakes of dry skin falling off of head and dandruff covered shoulders of shirt. The resident had a strong odor of urine.
Review of shower schedule on Maple hall showed the resident was scheduled to receive showers on day shift on Tuesdays and Fridays.
Review of facility provided shower logs and electronic bathing record, 9/18/23 to 12/14/23, showed
-9/18/23 resident received showers and was not shaved;
-9/29/23 resident refused offered shower twice;
-10/6/23 resident received shower and was not shaved;
-12/1/23 resident received shower, resident was dependent on helper to do all the effort;
-Resident received three showers out of 25 opportunities.
During an interview on 12/12/23 at 7:45 A.M., CNA F said:
- The resident will not allow staff to touch him;
-He/She was told during training that resident did all personal cares on his/her own and did not allow staff to help him;
-Resident completed personal cares by himself.
During an interview on 12/13/23 at 6:21 A.M., CNA D said:
-Resident would not allow him/her to assist with personal cares;
-He/She did not assist residents with showers.
3. Review of Resident #3's quarterly MDS, dated [DATE], showed:
-BIMS score of 15, which indicated resident was cognitively intact;
-The resident required set up or clean up assistance for eating, oral hygiene, and personal hygiene;
-The resident required partial to moderate assistance with bathing;
-Diagnoses included diabetes (a condition resulting in too much sugar in the blood) , stroke (damage to the brain from the interruption of blood supply), depression, history of falling, cognitive communication deficit, and mild mental retardation.
Review of care plan, dated 10/10/23, showed:
-Resident preferred showers in the morning twice weekly;
-Resident preferred to be shaved on shower days;
-Resident wanted hair washed during shower days.
-Resident has an activities of daily living performance deficit due to dementia and mild mental retardation;
-Check resident nail length and trim and clean on bath days and as necessary;
-Resident had dentures and required assistance with denture care.
Observation on 12/11/23 at 11:35 A.M, showed resident had not been shaved, hair was disheveled. The resident's denture cup on sink had brown stuff caked to to the lid and was not clean.
During an interview on 12/11/23 at 11:35 A.M., resident said:
-He/She did not get showers when he/she wanted them;
-He/She liked to be clean shaven;
-His/Her shower days were Mondays and Thursdays.
Review of shower schedule on Maple hall showed resident was scheduled to receive showers on day shift on Tuesdays and Fridays.
Review of facility provided shower logs from 10/6/23 to 12/13/23 showed:
-10/6/23 shower was received no shaving was offered;
-10/20/23 shower received no shaving was offered;
-11/31/23 shower was received.
During an interview on 12/12/23 at 7:45 A.M., CNA F said:
-Some resident like to refuse showers;
-When resident refuses showers staff keep offering showers throughout their shift;
During an interview on 12/13/23 at 6:21 A.M., CNA D said:
-He/She had no issues getting scheduled showers done on his/her shift;
-He/She notified nurse when resident refused showers;
-Nurse will talk to resident and see if they will change their mind;
-Receives scheduled shower sheets from nurse;
-Gives showers as needed during shift and as scheduled.
-Nurse documents shower refusals on shower sheet.
During an interview on 12/14/23 at 6:08 A.M., CNA G said:
-He/She can complete all scheduled showers during his/her shift;
-There is never enough staff working on floor.
During an interview on 12/14/23 at 04:43 P.M., the Director of Nursing said:
- Showers should be offered per the residents choice;
- Alternatives to promote hygiene should provided by staff when a resident refuses a shower.
During an interview on 12/14/23 at 5:00 P.M., the Administrator said all residents should be offered a bath/shower twice a week.
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 interview, observation, and record review, the facility failed to ensure that four of 20 sampled residents, (Residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure that four of 20 sampled residents, (Residents #45, #8, #25, and #33) who required staff assistance, were provided with adequate assistance for activities of daily living (ADL's: tasks completed to care for oneself daily such as bathing, dressing, moving from a chair to bed, and personal hygiene). The facility census was 82.
The facility did not provide a policy on ADLs.
1. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/17/23 showed:
- A Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment;
- The resident requires setup assistance for eating and oral hygiene;
- The resident is dependent on staff for toileting hygiene, rolling, bathing, and transfers;
- The resident is incontinent of urine and bowel;
- Has diagnoses of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), 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), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), hyperlipidemia (an elevated level of lipids, like cholesterol and triglycerides, in theblood), anxiety (a type of mental health condition that can cause feelings of fear, dread, and uneasiness), depression (a common mental disorder involving a depressed mood or loss of pleasure or interest in activities for long periods of time), severe obesity, and asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
Review of the resident's care plan, revised on 10/24/23 showed:
- The resident's desired personal care routine included: receiving two showers weekly;
- The resident prefers to be shaved with showers;
- The resident is dependent on staff for meeting his/her physical needs;
- He/She requires assistance with all ADLs;
- He/She has an ADL self-care performance deficit;
- He/She is totally dependent on 1-2 staff to provide bath/shower twice weekly and as necessary.
Review of undated facility shower schedule showed:
- Resident #25 was scheduled to receive showers every Wednesday and Saturday.
Review of facility's provided bath sheets and electronic bathing report documentation for the dates of 10/4/23 to 12/14/23 showed 21 scheduled shower dates.
- Showers given on 10/4/23, 10/21/23, 10/25/23, 11/8/23, 12/1/23, 12/3/23, 12/8/23, and 12/10/23;
- No documentation for the other 13 scheduled shower dates.
During an interview on 12/11/23 at 1:45 P.M., Resident #25 said:
- He/She has not been receiving two showers a week; - He/She prefers to have at least two showers a week;
- Missed showers occur at least monthly;
- He/She is not being shaved as much as he/she would prefer;- The resident prefers to be shaved with showers;
- It is a problem because he/she has problems with their skin and wants to remain clean;
- He/She gets frustrated when their showers are missed.
2. Review of Resident # 8's Quarterly MDS, dated [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The resident needs setup assistance for eating;
- Supervision for dressing upper body, while in bed- rolling left and right, sitting to lying;
- Moderate assistance for lying to sitting on bed;
- Substantial assistance with toileting, bathing, lower body dressing, putting on and taking off footwear, and transfers;
- Always incontinent of bowel and bladder;
- Diagnoses included rheumatoid arthritis (an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body), acquired absence of right leg below knee, contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints )to the right and left hands, and left foot.
Review of the resident's care plan, revised 12/12/23 showed:
- The resident has limited physical ability related to right below knee amputation, contractures, and disease process;
- The resident required one staff to assist with two showers weekly;
- The resident will be assisted with ADLs as needed as his/her physical condition changes;
- The resident requires one staff for transfers between surfaces.
Review of undated facility shower schedule showed:
- Resident #8 was scheduled to receive showers every Tuesday and Friday.
Review of facility provided bathing sheets and electronic bathing report documentation for the dates of 9/26/23 to 12/14/23(23 scheduled shower dates) showed:
- Shower refusals on 9/26/23 and 10/24/23
- Showers given on 10/10/23, 11/7/23, 12/3/23, and 12/10/23;
- No documentation for the other 17 scheduled shower dates.
During an interview on 12/11/23 at 12:12 P.M., the resident said:
- He/She is not getting two showers a week;
- His/Her showers are missed almost every week;
- He/She feels like crap when he/she does not get showered;
- He/She likes to feel clean;
- Has refused showers in the past but would still like to receive the other scheduled showers.
3. Review of Resident #33's Quarterly MDS, dated [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The resident is independent for eating;
- Requires set up assistance for oral hygiene,
- Supervision for personal hygiene;
- Moderate assistance for bathing;
- Substantial assistance for toileting hygiene, upper and lower body dressing, tolling left and right, sitting to lying, lying to sitting, sitting to standing, and all transfers;
- Dependent on staff for putting on and taking off footwear;
- Frequently incontinent of urine;
- Always incontinent of bowel;
- Diagnoses of Hemiplegia (paralysis of one side of body) after a stroke, cognitive communication deficit, difficulty walking, need for assistance with personal care, and seizures.
Review of the resident's care plan, revised 10/30/23 showed:
- The resident had an ADL self care deficit related to hemiplegia and a stroke;
- Staff should assist with ADLS as needed;
- The resident needs assistance with transfers;
- No information on required assistance with showers or bathing.
Review of undated facility shower schedule showed:
- Resident #33 was scheduled to receive showers every Tuesday evening and Friday evening.
Review of facility provided bathing sheets and electronic bathing report documentation for the dates of 10/1/23 to 12/14/23(21 scheduled shower dates) showed:
- No shower documentation for the month of October;
- Showers documented on 11/3/23, 12/1/23. 12/3/23, 12/8/23/ and 12/10/23;
-No documentation for the other 16 scheduled shower dates.
During an interview on 12/11/23 at 11:29 A.M., the resident said:
- He/She is not getting all of his/her showers;
- Staff tell him/her that they are too busy;
- He/She feels yucky when they don't get showers.
During an interview on 12/14/23 at 1:09 P.M. Certified Nursing Aide (CNA) I said:
- Residents should receive two showers a week;
- Residents can have more if they want or less if they refuse;
- Residents should be groom and shaved per their preference;
- Showers and refusals are documented on shower sheets and electronically.
During an interview on 12/14/23 at 1:21 P.M., Licensed Practical Nurse (LPN) G said:
- Residents should receive two showers a week;
- Residents can have more or less showers per their preference;
- Residents should be groomed to their preference.
4.Review of Resident #45's significant change MDS, dated [DATE], showed:
-Resident was cognitively intact;
-Required partial to moderate assistance with showers, toileting hygiene, and tub or shower transfers;
-Utilized motorized wheelchair for mobility;
-Diagnoses included: Congestive heart failure (fluid around the heart), lymphedema (a condition causing swelling in arm or leg caused by a lymphatic system blockage) , and generalized muscle weakness.
Review of care plan, dated 10/9/23, showed:
-Resident required one partial to moderate assistance by one staff with showering twice weekly and as necessary. Resident needed most assistance with lower body and back.
Review of face sheet, dated 12/14/23, showed resident admitted to facility on 10/5/23.
Observation on 12/11/23 at 2:25 P.M. showed resident had dry, flakey skin and hair was greasy, had not been combed/brushed or maintained.
During an interview on 12/11/23 at 2:25 P.M. resident stated:
-He/She had only received two showers since he/she arrived to the facility;
-He/She wanted showers three to four times a week.
Facility provided no requested bath logs for this resident.
Review of electronic bathing report documentation for the dates of 10/5/23 to 12/14/23 showed:
- No documentation of baths received;
-21 missed bath opportunities.
During an interview on 12/12/23 at 7:45 A.M., CNA F said:
-He/She had not given the resident a shower;
-He/She only did showers on the scheduled days she worked Maple hall and resident was not on his/her list.
During an interview on 12/13/23 at 6:21 A.M., CNA D said:
-He/She gave baths during his/her shift when they were scheduled and as needed;
-He/She received shower sheets to complete from the charge nurse;
-When resident refused showers he/she notified the nurse, the charge nurse would come talk to resident to see if resident was willing to change his/her mind.
-He/She did not have issues completing scheduled showers during his/her shift.
During an interview on 12/14/23 at 6:08 A.M., CNA G said he/she can complete all scheduled showers during his/her shift.
During an interview on 12/14/23 at 04:43 P.M., the Director of Nursing said:
- Showers should be offered per the residents choice;
- Alternatives to promote hygiene should provided by staff if a resident refuses.
During an interview on 12/14/23 at 5:00 P.M., the Administrator said all residents should be offered a bath/shower twice a week.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
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 [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #33's Quarterly MDS, dated [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The resident was independent for eating;
- Required set up assistance for oral hygiene,
- Supervision for personal hygiene;
- Moderate assistance for bathing;
- Substantial assistance for toileting hygiene, upper and lower body dressing, rolling left and right, sitting to lying, lying to sitting, sitting to standing, and all transfers;
- Dependent on staff for putting on and taking off footwear;
- Frequently incontinent of urine;
- Always incontinent of bowel;
- Diagnoses of Hemiplegia (paralysis of one side of body) after a stroke, cognitive communication deficit, difficulty walking, need for assistance with personal care, and seizures.
Review of resident's physician's orders, dated December 2023 showed:
- Resident may have hand rail on bed to help with mobility while in the bed and mobility to get in and out of bed;
- An order date of 12/13/23.
Review of the resident's care plan, revised 10/30/23 showed:
- The resident had an Activity of Daily Living (ADL) self care deficit related to hemiplegia and a stroke;
- The resident needs assistance with transfers;
- The resident had a hand rail on the bed that he/she uses for bed mobility and to help him/her stand and transfer.
Review of electronic medical record, dated 12/13/23, showed:
- No entrapment assessment located in chart;
- A bed rail safety review indicating assist bar - bed rail safety not indicated at this time on 9/25/23;
- One bed rail assessment completed on 12/13/23.
Review of maintenance log book, undated, showed:
-No log sheet with measurements for this resident's room number or by his/her name.
Observation on 12/11/23 at 11:35 A.M., showed:
- The resident had a quarter rail on right side of bed;
- The resident resting in bed.
During an interview on 12/11/23 at 11:35 A.M., the resident said:
- He/She used the rails to help him/her move in bed.
4. Review of Resident #5's annual MDS, dated [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The resident was independent for eating, oral hygiene, upper body dressing, and personal hygiene;
- Supervision for rolling left and right, sitting to lying, and lying to sitting;
- Moderate assistance for putting on and taking off footwear, sitting to standing, toileting transfers, and bed to chair transfers;
- Substantial assistance with toileting hygiene and lower body dressing;
- Diagnosis of heart failure, severe obesity, obstructive sleep apnea, asthma, unsteadiness on feet, and repeated falls.
Review of resident's physician's orders, dated December 2023 showed:
- Resident may have half rails bilaterally at head of bed to assist resident with bed mobility and promote independence.
Review of the resident's care plan, revised 11/7/23 showed:
- The resident had an ADL self care performance deficit;
- The resident had side rails on bilaterally at head of bed that the resident used to pull self up, assist in turning and repositioning in bed, used to assist in standing up from the side of bed due to back and leg pain.
Review of electronic medical record showed:
- No entrapment assessment located in chart;
- A bed rail, grab or assist bar safety review completed on 2/1/23 and 7/8/23 during a quarterly screening, both documented an assist bar - bed rail safety not indicated at this time;
- Bed rail assessments done on 4/28/2023, 11/27/2023, and 12/13/23.
Review of maintenance log book, undated, showed:
-No log sheet with measurements for this resident's room number or by his/her name.
Observation on 12/12/23 at 10:24 A.M., showed:
- Half rails on both sides of the head of the bed;
- The resident was resting in bed.
During an interview on 12/12/23 at 10:24 A.M., the resident said:
- He/She used the bar to help reposition and move around the bed.
During an interview on 12/14/23 at 6:03 A.M., Maintenance Director said:
-He/She installed bed rails on the residents bed after therapy requested the rails;
-He/She did measurements when the resident got bed and side rails were added;
-He/She had not done entrapment assessments.
During an interview on 12/14/23 at 7:09 A.M., Maintenance Assistance said:
-Installed side rails only when therapy wrote on maintenance log;
-He/She checked side rails in facility monthly to ensure side rails were tight on bed;
-He/She wrote down measurements in log book kept by maintenance that had resident room number
During an interview on 12/14/23 at 5:22 P.M., the Director of Nursing (DON) said:
-Any piece of equipment including bed rails that come into contact with resident should be reviewed to ensure it is safe;
-Bed rails should be assessed via risk versus need for each resident;
-Side rail assessments are completely be nursing staff;
-Side rails should be reviewed on initial installation and quarterly.
Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation for and failed to ensure the bed's dimensions were appropriate for the resident's size and weight, and failed to ensure scheduled maintenance of any bed rail, and failed to use an alternative to side rails, for four of 18 sampled residents (Resident,#40, #35, #5 and #33). The facility census was 82.
Review of facility policy, Bed Maintenance and Inspections, dated 2022 showed:
-It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify and avoid areas of possible entrapment.
-The maintenance director, or designee, is responsible for keeping records of bed inspections and maintenance.
-A list of bed frames, mattresses, and bed rails will be maintained, including the manufacturer for each. The maintenance director shall be notified of any new equipment brought into the facility.
-The Maintenance Director shall review each manufacturer's recommendations and requirements for maintenance and bed inspections, and shall establish a maintenance and inspection schedule accordingly.
-Bed rails shall be securely and properly installed according to manufacture's requirements.
-The facility will ensure bed rails, mattress, and bed frame are compatible.
-Bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility and then placed on a regularly scheduled inspection and maintenance cycle
1. Review of Resident #40's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/26/23 showed:
-Moderately impaired cognition;
-Required substantial or maximal assistance with shower and bathing self, lower body dressing, sitting to standing mobility, chair to bed transfers;
-Required partial or moderate assistance with toileting hygiene, toilet transfers, and moving from lying to sitting on the side of the bed;
-Used manual wheelchair;
-Had no physical restraint used for bed rail;
-Diagnoses included hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (one sided muscle weakness) following stroke affecting left-non-dominant side, generalized muscle weakness, sensorineural hearing loss (the inner ear nerve responsible for transmitting sounds are damaged), and metabolic encephalopathy (condition that can lead to personality changes).
Review of physician's orders, dated December 2023, showed side rails for bed mobility, positioning, and transfer assistance.
Review of care plan, dated 12/11/23, showed:
-Resident had side rails in place for bed mobility due to decreased mobility following stroke with left sided paralysis;
-Resident was a fall risk due to gait, balance, and mobility problems;
-Resident will use side rail to maintain bed mobility and assist with positioning and transfer;
-Evaluation for use of side rails will be completed prior to side rail placement and will
be reviewed quarterly;
-Resident or Power of Attorney (POA) will sign consent prior to side rail placement and will renew consent yearly;
-Resident will demonstrate the ability to safely use side rails for positioning, transfer, and bed mobility.
Review of bed rail use assessment form, dated 5/8/23, showed:
-No alternative attempted prior to bed rails;
-Resident requested bed rails for mobility and transfer assistance;
-Benefits included to assist resident with movement, turning side to side, assist with balance with attempting to stand, and assist with getting in and out of bed;
-No potential risks identified for use of bed rails;
-Taking medications that indicate need for additional safety measures
-Interdisciplinary team recommended bed rails installed because resident requested;
-No physical therapy or occupational therapy or restorative evaluation was indicated;
-Recommended type of bed rail included right side U-bar.
-Recent height 69.0 on 2/5/23 by laying down
-Recent weight 173.0 lbs on 4/4/23 via wheelchair
-No quarterly assessment completed.
Review of electronic medical record, dated 12/13/23, showed no entrapment assessment had been completed.
Review of maintenance log book, undated, showed no log sheet with measurements for this resident's room number or by his/her name.
Observation on 12/11/23 at 11:37 A.M., showed resident had quarter side rail on right side of bed closest to the wall.
During an interview on 12/13/23 at 6:21 A.M., Certified Nurses Aide (CNA) D said the Resident is paraplegic on left side and that is the reason he had bed rail in his room
2. Review of Resident #35's quarterly MDS, dated [DATE], showed:
-Intact cognition;
-Supervised or touching assistance for toileting and upper body dressing;
-Independent with rolling, sitting to lying, lying to sitting on side to bed, chair to bed transfers, and toilet transfers;
-Used a manual wheelchair;
-Diagnoses included osteoarthritis of right hip (a degenerative disease that worsens over time resulting in chronic pain), polyneuropathy (many nerves in different parts of the body causing weakness, numbness, and pain from nerve damage), intervertebral disc degeneration of lumbar region (loss of cushioning, fragmentation, and herniation related to aging), generalized muscle weakness, difficulty in walking, dementia (a group of thinking and social symptoms that interferes with daily functioning characterized by impairment of at least two brain functions), and chronic pain syndrome.
Review of resident's physician's orders, dated December 2023, showed:
-U-bar to bed for assistance with bed mobility and transfers.
Review of care plan, dated 10/23/23, showed:
-U-bar to right side of bed for bed mobility and self transfers;
-He/She was able to turn and reposition self in bed with supervision or touching assistance.
Review of bed rail use assessment form, dated 6/28/23, showed:
-No alternative attempted prior to bed rails;
-Resident requested bed rails for mobility and transfer assistance;
-Benefits included to prevent resident from falling out of bed, assist resident with movement within bed, assist with turning side to side, provide resident with feeling of comfort and security for fear of falling out of bed, assist with balance while attempting to stand, assist with getting in and out of bed, and to define the bed edge;
-No potential risks identified for use of bed rails;
-Interdisciplinary team recommended bed rails installed because resident requested;
-No physical therapy or occupational therapy or restorative evaluation was indicated;
-Recommended type of bed rail included right side U-bar;
-Recent height 63.0 on 2/5/23 by laying down;
-Recent weight 189.0 lbs on 6/16/23 via standing scale;
-No quarterly assessment completed;
-Bed rail installed 6/28/23.
Review of electronic medical record, dated 12/13/23, showed no entrapment assessment located.
Review of maintenance log book, undated, showed no log sheet with measurements for this resident's room number or by his/her name.
Observation on 12/11/23 at 12:31 P.M. showed the resident was in bed, he/she had a quarter rail on right side of bed.
During an interview on 12/11/23 at 12:31 P.M., the resident said the side rail was to help pull him/her up or pull him/her sideways in bed.
During an interview on 12/13/23 at 6:21 A.M., CNA D said the Resident used the side rail to pull themselves up and down and for support.
During an interview on 12/14/23 at 6:04 A.M., the Maintenance Director said:
-He/She installed bed rails on residents beds after therapy requested for them to be put on;
-He/She kept track of which residents had side rails on in a book maintained in maintenance office;
-He/She made sure mattress fits the frame, some mattresses did not fit frame exactly;
-He/She did measurements when bed were received;
-When mattress did not fit the bed he/she spoke to central supply to get another mattress ordered that will fit the frame;
-He/She did not complete entrapment assessments;
-His/Her assistant checked maintenance book for any problems at each nurses stations and facility front desk;
During an interview on 12/14/23 at 7:09 A.M., the Maintenance Assistance said:
-He/She did installation of side rails only through therapy department and would write those in maintenance log;
-He/She measured bed frames and mattress sizes;
-Mattress sizes and frames are usually the same size unless they are a bariatric bed;
-He/She documented measurements on a note pad and then wrote on document in office;
-Measurements are maintained in the maintenance office;
-He/She checked side rails in facility monthly by making sure side rails were tight on bed and not loose;
-He/She did measurements from head of bed to where he was going to put mattress and also between middle of bed and headboard;
-He/She documented measurements in maintenance log book with what room number resident was in.
During an interview on 12/14/23 at 4:43 P.M, the Director of Nursing (DON) said:
-Any piece of equipment that came into contact with a resident should be reviewed to ensure it is safe including bed rails;
-Maintenance was responsible for completing entrapment assessments;
-Entrapment assessments should be completed upon initial installation and quarterly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility census was 82.
1. R...
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Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility census was 82.
1. Review of the facility's staffing timesheets, dated 04/01/23 to 5/31/23, showed no RN coverage for the following dates:
-04/08/23;
-04/09/23;
-05/13/23;
-05/21/23;
-05/29/23;
-05/30/23; and
-05/31/23.
Review of facility's timesheets, dated June 2023, showed RN coverage as the DON for eight hours no clock in or out.
During an interview, on 12/14/23 at 04:43 P.M., the Administrator and Director of Nursing (DON) said they do not believe that they have had that many days without an RN, especially now that the DON is working in the building most days. They believe that the change in owner on June 1st is part of the problem and they have started a Quality Assurance and Performance (QAPI) Performance Improvement Project (PIP) for the staffing issues.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 ensure staff administered medications with a medicati...
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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 ensure staff administered medications with a medication error rate of less than 5%. Facility staff made two medication errors out of 25 opportunities for error which resulted in a medication error rate of 8%, which affected two out of 20 sampled residents, (Resident #13 and #16). The facility census was 82.
The facility did not provide a policy for administration of medications.
1. Review of Resident #16's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/23 showed:
- A Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment;
- The resident needs setup assistance with eating, oral hygiene, and personal hygiene;
- Dependent of staff for medication management, toileting hygiene, bathing, lower body dressing, putting on and taking off footwear, and shower transfers;
-Diagnoses of Hemiplegia (paralysis of one side of body) after a stroke, dysphagia (difficulty swallowing), cognitive communication deficit, gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), anemia (an iron deficiency) loss of ability to understand or express speech after a stroke.
Review of Resident #16's physician order sheet, dated December 2023 showed:
- Ferrous Sulfate Syrup 300 (60 Fe) MG/5ML, give 5 ml by mouth one time a day for anemia, with a start date of 10/22/22.
Review of the resident's medication administration record, dated December 2023, showed:
- Ferrous Sulfate Syrup 300 (60 Fe) MG/5ML, give 5 ml by mouth one time a day for anemia, with a start date of 10/22/22.
Observation on 12/13/23 at 7:05 A.M. showed:
- Certified Medication Technician (CMT) C provided the resident an iron ferrous sulfate 325 mg tablet.
2. Review of Resident #13's quarterly MDS dated [DATE] showed:
- A BIMS score of 11, indicating moderately impaired cognition;
- Setup assistance for eating, oral hygiene, rolling left and right, sitting to lying, and toilet transfers;
- Supervision for toileting hygiene, upper body dressing, and chair to chair transfer;
- Moderate assistance with medication management, bathing, lying to sitting, sitting to standing, and shower transfers;
- Diagnosis of Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) , cognitive impairment, benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), and diabetes(a chronic 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 Resident #13's physician order sheet, dated December 2023 showed:
- Tamsulosin HCL 0.4 mg capsule, give 1 capsule by mouth, one time a day for benign prostatic hyperplasia, do not crush, chew, or open, take approximately 30 minutes after meal/food.
Review of the resident's medication administration record, dated December 2023, showed:
- Tamsulosin HCL 0.4 mg capsule, give 1 capsule by mouth, one time a day for benign prostatic hyperplasia, do not crush, chew, or open, take approximately 30 minutes after meal/food.
Observation on 12/13/23 at 7:02 A.M. showed:
- CMT C provided the resident a Tamsulosin HCL 0.4 mg capsule;
- Breakfast had not yet been served.
Observation on 12/13/23 at 8:00 A.M. showed:
- The resident was served breakfast in the dining room.
During an interview on 12/14/23 at 12:30 P.M. Licensed Practical Nurse (LPN) G said:
- Physicians orders should be followed;
- An order would have to in place to switch from a syrup medication to a tablet;
- There was no order to switch from a syrup medication to a tablet for Resident #16.
During an interview on 12/14/23 at 12:34 P.M., Certified Medication Technician (CMT) C said:
- Physicians orders should be followed;
- Orders that give directions for the treatment or medication to be administered before or after meals should be followed;
- Resident #16 should have received 300 MG ferrous sulfate syrup, not a 325 MG ferrous sulfate tablet;
- He/She realized the mistake during the morning med pass on 12/14/23.
During an interview on 12/14/23 at 4:43 P.M., the Director of Nursing said:
- Physicians orders should be followed;
- The facility had recent onsite training with Pharm- America;
- He/She knew that there are some issues with medication passes.
- Medication errors should be reported to the resident's physician and facility administration.
During an interview on 12/14/23 at 5:05P.M., the Administrator said:
- Medications should be given to the residents per the physician's order and missed medications, or medication errors must be reported to the resident's physician, and well as the nursing administrative staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident # 15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident # 15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/23 showed:
-Brief interview of mental status (BIMS) score of 11, indicating moderate cognitive impairment.
-The resident is independent with eating, toileting hygiene, and dressing.
-The resident requires moderate assistance with showers.
-Diagnoses of prostate cancer, hypertension (high blood pressure), diabetes mellitus (abnormal glucose level), and dementia (impairment in intellectual functioning).
Review of Resident #15's Care Plan, revised 4/14/23 showed:
-The resident had diabetes mellitus ( A condition where the blood containes high amounts of sugar.)
-The care plan contained no information regarding diabetes.
Review of Resident #15's August, October, November, and December Physician's order sheets., showed:
-Blood sugars to be checked before meals and at bedtime.
-Humulin R injection medication solution (insulin Regular Human) - Inject 4 units subcutaneously with meals for diabetes mellites which was ordered on 8/28/23.
-Insulin Glargine Solution 100 UNIT/ML Inject 22 units subcutaneously at bedtime for diabetes which was ordered on 8/28/23.
-Insulin Glargine Solution 100 UNIT/ML Inject 5 units subcutaneously one time a day, but no specific time of day indicted for diabetes which was ordered on 8/28/23.
Review of Resident #15's Treatment Administration Record (TAR) for October 2023 showed:
-No documentation of medication administration of Humulin R insulin 4 units on 10/1/23 for 8 A.M, 12 P.M or 5 P.M. when the order shows insulin is ordered for 8:00 A.M., 12:00 P.M., and 5:00 P.M. (with meals).
-No documented administration of medication Insulin Glargine 5 units at 8:00 A.M. on 10/1/23.
-No documented administration of medication Insulin Glargine 22 units at 5:00 P.M. on 10/1/23.
- No documented administration of medication Humulin R insulin 4 units on 10/2/23. Order shows insulin is ordered for 8:00 A.M., 12:00 P.M., and 5:00 P.M. (with meals).
- No documented administration of medication Insulin Glargine 5 units at 8:00 A.M. on 10/2/23.
- No documented administration of medication Insulin Glargine 22 units at 5:00 P.M. on 10/2/23.
Review of Resident #15's TAR for November 2023 showed:
-No documented administration of medication Humulin R insulin 4 units 12:00 P.M. dose on 11/17/23, 11/20/23, 11/21/23, 11/22/23, 11/23/23 and 11/28/23.
-No documented administration of medication Insulin Glargine 5 units on 11/20/23, 11/21/23, 11/22/23.
-No documented administration of medication Insulin Glargine 22 units on 11/20/23, 11/21/23, 11/22/23, and 11/23/23.
Review of Resident #15's TAR for December 2023 showed:
-No documented administration of medicationHumulin R insulin 4 units at 8:00 A.M. on 12/5/23, 12/8/23, and 12/9/23.
-No documented administration of medication Humulin R insulin 4 units at 12:00 P.M. on 12/7/23, 12/8/23, 12/9/23, and 12/10/23.
-No documented administration of medication Humulin R insulin 4 units at 5:00 P.M. on 12/7/23, 12/8/23, 12/9/23, and 12/10/23.
-No documented administration of medication Insulin Glargine 5 units at 8:00 A.M. on 12/5/23, 12/8/23, 12/9/23, and 12/10/23
During an interview and observation on 12/12/23 at 2:10 P.M., the resident said:
- He/She knew he/she was a diabetic.
- He/She knew the facility staff give him his/her medication and check his/her blood sugar.
- Observing the resident, and based on cognition, he/she would not know if blood sugar monitoring or insulin was missed.
During an interview on 12/14/23 at 4:P.M., Licensed Practical Nurse (LPN) A., said if a space on MAR or TAR is blank, then nothing was done or administered at that time.
During an interview on 12/14/23 at 4:15 P.M., with Certified Med Tech (CMT) A., said a blank space on MAR or TAR means medication was not given.
During an interview on 12/14/23 at 4:43 P.M., the Director of Nursing (DON) said:
-Physician's orders should be followed.
-The facility had a recent onsite training with Pharm-America.
-He/She knew that there are some issues with medication passes.
During an interview on 12/14/23 at 4:45 P.M., the Administrator said when a medication is not given, or is missed, it is to be reported the resident's physician immediately as well as to the Administration team.
Based on observations, interviews and record review, the facility failed to ensure staff did not make significant medication errors when they failed to follow physicians' orders to check blood sugars and administer insulin as ordered. This affected three of 20 sampled residents (Residents #15, #20, and #25). The facility census was 82.
Review of the facility's Timely Administration of Insulin policy, dated 9/1/21 showed:
- It is the policy of the facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition;
- All insulin will be administered in accordance with physician's orders;
- For current insulin orders, an adequate supply of insulin will be maintained for each resident;
- Insulin will be reordered as needed according to facility policy;
- Insulin administration will be coordinated with mealtimes and bedtime snacks unless otherwise specified in the physician order.
1. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/17/23 showed:
- Brief interview of metal status (BIMS) score of 15, indicating no cognitive impairment;
- The resident requires staff to provide diabetic management with medications and monitoring.
- The resident is dependent on staff for toileting, hygiene, rolling, bathing, and transfers;
- Diagnoses of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), anxiety (a type of mental health condition that can cause feelings of fear, dread, and uneasiness)
Review of the resident's active physicians order sheet, dated 12/14/23 showed:
- An order to check blood sugars before meals, hour of sleep, and as needed:
- Insulin Aspart injection per sliding scale if 201-250 = 2 units, 251-300 = 5 units, 301-350= 8 unit, 351-400= 12 units, given subcutaneously before meals for diabetes;
- Insulin Demtemir solution 100 unit/ml inject 15 unit subcutaneously in morning for diabetes;
- Insulin Demtemir solution 100 unit/ml inject 52 unit subcutaneously at bedtime for diabetes;
- Novolog Flexpen subcutaneous solution 100 unit/ml, inject 10 units subcutaneously before meals for diabetes and give 10 unites before meals with sliding scale.
Review of the resident's care plan, revised 10/24/23 showed:
- The resident is a diabetic;
- Diabetes medications should be administered at ordered by doctor;
- Accu-checks (a test to check the sugar level in the blood) before meals and at bedtime.
Review of the resident's medication and treatment administration records for 12/1/23 to 12/13/23 showed:
- The order for insulin Demtemir solution 100 unit/ml inject 15 unit subcutaneously in morning for diabetes was not completed on 12/8/23 and 12/10/23;
- The order for insulin Demtemir solution 100 unit/ml inject 52 unit subcutaneously at bedtime for diabetes was not completed on 12/10/23;
- The orders for insulin Aspart injection per sliding scale if 201-250 = 2 units, 251-300 = 5 units, 301-350= 8 unit, 351-400= 12 units, given subcutaneously before meals for diabetes and Novolog Flexpen subcutaneous solution 100 unit/ml, inject 10 units subcutaneously before meals for diabetes and give 10 unites before meals with sliding scale were not completed on the midday meals on 12/8/23 and 12/10/23 and evening meals on 12/10/23 and 12/11/23;
- The order to check blood sugars before meals, hour of sleep, and as needed was not completed before the morning meal on 12/8/23, no blood sugar checks on all three meals on 12/10/23, and no check before the midday meal on 12/11/23.
During an interview on 12/13/23 at 9:11 AM, Resident #25 said:
- He/She had not gotten his/her morning insulin;
- The insulin should be administered before breakfast;
- Breakfast had already been served;
- He/She needs insulin because he/she commonly has high blood sugars and diabetes.
During observation and interview on 12/14/23 showed:
- Resident #25 did not receive insulin with morning med pass prior to him/her eating breakfast at 8:31 A.M.;
-Resident #25's blood sugars were not checked prior to him/her eating breakfast at 8:31 A.M.
During an interview on 12/14/23 at 12:34 P.M., Certified Medication Technician (CMT) C said:
- Physicians orders should be followed;
- Orders that give directions for the treatment or medication to be administered before or after meals should be followed.
During an interview on 12/14/23 at 1:21 P.M., Licensed Practical Nurse (LPN) G said:
- Insulin and blood sugar checks should be administered per physician's orders;
- Resident #25's orders for insulin and accu-checks before meals should have been administered before he/she ate.
2. Review of Resident #20's quarterly MDS, dated [DATE]., showed:
- BIMS score of 15 indicating that resident is cognitely intact.
- Dependent on staff for medication administration and insulin administration.
- Diagnoses includes: Diabetes Mellitus (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), Diabetic Neuropathy (painful tingling in the hands and feet as a result of diabetes), and history of Tramatic Brain Injury.
Review of the resident's care plan, date 4/28/21., showed:
- Resident has history of Tramatic Brain Injury.
- Resident has Diabetes Mellitus Type 2.
- Diabetes medication as ordered, and monitor for side effects.
- Check blood sugars before meals and at bedtime.
- Notify the physician is above 400 or below 60.
Review of the resident's Physician order sheet for November and December., showed:
- Novolog flex pen solution pen injector per sliding scale: 150= 2 units, 200= 4 units, 250= 5 units, 300= 9 units, 350=12 units, 400= 15 units, 450=18 units, and 500=21 units after meals and at bed time.
- Blood glucose monitoring before meals and at bedtime.
Review of the resident's November and December Medication Administration Record, showed:
-Missed doses of Novolog flex pen solution pen medication injection per sliding scale on
November 11, 17, 19, 20,21,22, and 28th.
-Missed blood glucose monitoring on November 5, 11,14,19,20,21,22, and 28th.
-Missed doses of Novolog flex pen solution pen medication injection per sliding scale for December 1,5,7, 8, 9, 10, 11, 12.
-Missed blood glucose monitoring on December 1, 5,7,8,9,10,11,and 12th.
Observation on 11/12/23 at 1:05 P.M., showed LPN B-Administer insulin in right arm while resident was sleeping.
During an interview on 11/12/23 at 4:25 P.M., Resident #20 said:
- He/She was not aware if he had missed any insulin or finger sticks.
During an interview on 12/12/23 at 4:P.M., Licensed Practical Nurse (LPN) B., said a blank space on MAR or Treatment means that nothing was done or administered at that time.
During an interview on 12/14/23 at 5:00 P.M., the interium Director of Nursing said a blank space on the medication or treatment record would indicate it was not done or not given, if that is the case then the physician should be notified along with facility administration as to why.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
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 serve meals according to scheduled meal times. This a...
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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 serve meals according to scheduled meal times. This affected two of 18 sampled residents (Residents #33 and #25) . This had to potential to impact all residents residing in the community. The facility census was 82.
Review of the facility posted meal times showed:
-Breakfast to be served at 7:30 A.M.
-Lunch to be served at 11:30 A.M.
-Dinner to be served at 5:30 P.M.
Review of facility policy, Food Safety Requirements, dated February 2023, showed:
-Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature;
-Timely distribution of all meals/snacks.
1. Observation on 12/11/23 at 9:43 A.M. showed breakfast hall trays on Maple hall being served two hours and 13 minutes after posted meal time.
Observation on 12/11/23 at 1:15 P.M. showed the first lunch tray served on the hall. All trays were served in resident rooms due to COVID-19 (a respiratory virus that is highly infections) outbreak.
Observation on 12/11/23 at 1:20 P.M. on [NAME] hall showed nursing staff serving drinks to the residents in their rooms. on hall. Nursing staff said residents were eating in rooms due to COVID-19 outbreak. Five residents in [NAME] dining room area were waiting for lunch to be served to them.
Observation on 12/11/23 at 1:22 P.M. showed trays had not been served on Maple Hall. Certified Nurse Aide (CNA) E and Certified Medication Technician (CMT) A served residents lunch drinks in resident rooms.
Observation on 12/11/23 at 1:31 P.M. showed food cart arrived to [NAME] hall.
Observation on 12/11/23 at 2:00 P.M., showed residents sitting at the top of the [NAME] hall dining area and had not received their lunch meal trays. When nursing and ancillary staff were questioned they said they had forgotten them.
Observation on 12/11/23 at 2:08 P.M. showed trays being passed on [NAME] Hall, two hours and 38 minutes past scheduled meal service times.
Observation on 12/12/23 at 8:51 A.M., showed breakfast had not been delivered to Maple hall.
2. Review of Resident #33 ' s Quarterly Minimum Data Set (MDS), dated [DATE] showed:
- A Brief Interview Mental Status (BIMS) score of 15, indicating no cognitive impairment;
- The resident was independent for eating;
- Diagnoses of Hemiplegia (paralysis of one side of body) after a stroke, cognitive communication deficit, difficulty walking, need for assistance with personal care, and seizures
During an interview on 12/11/23 at 11:27 A.M, the resident said the food took a long time to arrive to his/her room;
- When the food arrived it was cold.
3. Review of Resident #25's quarterly MDS, dated [DATE] showed:
- A BIMS score of 15, indicating no cognitive impairment;
- The resident required setup assistance for eating and oral hygiene;
- Diagnoses of heart failure, renal insufficiency, diabetes, hyperlipidemia, anxiety, depression, severe obesity, and asthma.
During an interview on 12/11/23 at 1:54 P.M, Resident said he/she had not received his/her lunch. He/She often waited for his/her meals to be served.
During an interview on 12/12/23 at 7:45 A.M., CNA E said:
-He/She did not know what hall tray meals times were;
-The kitchen staff usually brought drinks to the hallways first;
-Maple hall was usually the last hall to receive their meal cart;
-The kitchen serves the Village, then the dining room, then [NAME] hall, then finishes on Maple hall;
-Meal service times depends on the day of the week and what staff was working in the kitchen.
During an interview on 12/14/23 at 4:24 P.M., [NAME] C said:
-The kitchen staff had to wait until a nurse told the kitchen staff if residents were eating in the dining room or in their rooms.
During an interview on 12/14/23 at 4:28 P.M., [NAME] A said:
-On 12/11 there was a delay in lunch service due to the dishwasher being fixed and not being able to wash breakfast dishes right away;
-Meals were late sometimes because the kitchen staff had to wait to serve for the dishes to be washed.
During an interview on 12/14/23 at 4:37 P.M., [NAME] E said:
-No issues with meal service time, kitchen always waiting on CNA's;
-The kitchen staff often have to wait to serve the meal because there was not a nurse in the dining room;
-The residents who reside on the Village hall were always served first, then the main dining room, [NAME] hall, and Maple hall.
During an interview on 12/14/23 at 4:44 P.M., [NAME] F said:
-Meal served late was not an issue with the kitchen staff, but with the nursing staff being understaffed;
-He/She had to find a nurse to find out of residents were or were not eating in the dining room each day;
During an interview on 12/14/23 at 4:51 P.M., Dietary Manager said:
-Kitchen staff prepares the meal on time, the issue was the nursing staff ensuring the residents were available for meals;
-Sometimes kitchen staff was waiting on hall carts to return to kitchen so dishes can be washed before next meal;
-It was nursing staff responsibility to take the hall carts and dirty dishes to the kitchen after the meal;
During an interview on 12/14/23 at 5:22 P.M., the Administrator said:
-He/She expected meals to be served whenever resident wanted them to be served;
-Meals should be served at posted meal times;
-Delay in service on 12/11/23 was due to working on plumbing in in in kitchen.
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 maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff failed to follow acceptable standards of practice for the 2019 Novel Coronavirus Disease COVID-19 (COVID-19,(an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)), when staff failed to apply and properly wear personal protective equipment (PPE) when entering Covid-19 positive rooms (Residents #35, #48, and #332), failed to sanitize or wash hands (Residents #35, #48, and #332,) , left a resident's door open who was Covid positive (Resident #332), and when the facility failed to provide doffing containers in resident's rooms (Resident #35, #48, and #332,). This affected three of 18 sampled residents (Residents #35, #48, and #332,). The facility census was 82.
Review of the facility's Infection Control Policy, revised on 5/15/23, showed:
- This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infection as per accepted national standards and guidelines.
-Isolation Protocol: A resident with an infection or communicable disease shall be placed on transmission -based precautions as recommended by current Center for Disease Control (CDC) guidelines. All staff shall use PPE in accordance with the facility policy and current CDC guidelines. Isolations signs will be posted to alert staff and visitors.
Review of CDC recommended practices for routine infection prevention and control in all healthcare settings (including nursing homes), dated 5/8/23, showed:
-Source control recommended for individuals have suspected or confirmed SARS-CoV-2 infection or other respiratory infection or had close contact with someone with SARS-CoV-2 infection.
-Source control options include:
-A NIOSH Approved® particulate respirator with N95® filters or higher;
-A respirator approved under standards used in other countries that are similar to NIOSH
Approved N95 filtering face piece respirators
-A well-fitting facemask.
-When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. - Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed if safe to do so.
-Health Care Professionals who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection.
-Wear gloves when it can be reasonably anticipated that contact with blood or other
potentially infectious materials, mucous membranes, non-intact skin, potentially
contaminated skin or contaminated equipment could occur.
-Wear a gown that is appropriate to the task to protect skin and prevent soiling of
clothing during procedures and activities that could cause contact with blood, body
fluids, secretions, or excretions.
-Use protective eyewear and a mask, or a face shield, to protect the mucous membranes
of the eyes, nose and mouth during procedures and activities that could generate
splashes or sprays of blood, body fluids, secretions, and excretions. Select masks,
goggles, face shields, and combinations of each according to the need anticipated by the
task performed.
-Remove and discard PPE, other than respirators, upon completing a task before leaving
the patient's room or care area. If a respirator is used, it should be removed and
discarded after leaving the patient room or care area and
closing the door.
-Do not use the same gown or pair of gloves for care of more than one patient. Remove
and discard disposable gloves upon completion of a task or when soiled during the
process of care.
-Ensure that healthcare personnel have immediate access to and are trained and able to
select, put on, remove, and dispose of PPE in a manner that protects themselves, the
patient, and others.
1. Review of Resident #35's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/13/23 showed:
-Intact cognition;
-Supervised or touching assistance for toileting and upper body dressing;
-Independent with rolling, sitting to lying, lying to sitting on side to bed, chair to bed transfers, and toilet transfers;
-Used a manual wheelchair;
-Diagnoses included osteoarthritis of right hip (a degenerative disease that worsens over time resulting in chronic pain), polyneuropathy (many nerves in different parts of the body causing weakness, numbness, and pain from nerve damage), inter-vertebral disc degeneration of lumbar region (loss of cushioning, fragmentation, and herniation related to aging), generalized muscle weakness, difficulty in walking, dementia (a group of thinking and social symptoms that interferes with daily functioning characterized by impairment of at least two brain functions), and chronic pain syndrome.
Review of care plan, dated 12/8/23, showed:
-Resident positive for COVID-19 respiratory infection;
-Continue facility wide CMS approved infection control surveillance;
-Droplet isolation: Keep door to room closed ;
- Staff and Visitors to wear PPE at all times while in room:
- Wash/Sanitize hands upon entering and exiting room;
- Limit/Restrict visitors;
- Resident isolated to his/her room.
Review of electronic medical record showed:
-On 12/8/23 at 10:47 A.M. the nurse said resident tested positive for COVID- 19. Staff reported resident had increased coughing on 12/6/23 and 12/7/23. The resident may come off of isolation on 12/19/23.
Observation on 12/11/23 at 11:34 A.M. outside of resident's room showed a PPE tote gowns and face shields only. Inside the room showed the trash can was full and overflowing and there was no doffing container for PPE in the room.
Observation on 12/11/23 at 12:39 P.M. showed the resident left the room for smoke break wearing only a surgical mask. On the way down hall the resident was observed to touch a sleeve of plastic cups on medication cart to keep them from falling.
Observation on 12/13/23 at 8:03 A.M. showed the resident was out of his/her room wearing only a surgical mask. He/She was headed back to room from participating in a smoke break when Licensed Practical Nurse (LPN) A met the resident in the hallway and handed the resident his/her medications in a pill cup. LPN A was not wearing gloves.
2. Review of Resident #48's significant change MDS, dated [DATE] showed:
-Unable to determine cognition level;
-Dependent for bathing assistance;
-Substantial/maximal assistance for oral hygiene;
-Partial to moderate assistance required for toileting, dressing;
-Supervision or touching assistance for mobility;
-Supervised or touching assistance for toileting and upper body dressing;
-Independent with rolling, sitting to lying, lying to sitting on side to bed, chair to bed transfers, and toilet transfers;
-Diagnoses included Huntington's disease (a condition that causes the progressive breakdown of nerve cells in the brain), migraines, pain in knee, and Coronavirus disease (an infectious disease cause by the SARS-CoV-2 virus).
Review of care plan, dated 12/8/23, showed:
-Resident positive for COVID-19 respiratory infection;
-Continue facility wide CMS approved infection control surveillance;
-Droplet isolation: Keep door to room closed
-Staff and Visitors to wear PPE at all times while in room:
-Wash/Sanitize hands upon entering and exiting room
- Limit/Restrict visitors
- Resident isolated to his/her room
Observation on 12/11/23 at 12:13 P.M., in resident's room showed there was no doffing container in the room.
Observation on 12/12/23 at 7:28 A.M. showed Registered Nurse (RN) A and CNA F donning PPE but they could not locate face shields or gloves outside of the room. CNA F walked from out of the residents room and down the hall to find available gloves. No doffing container was available in the room for PPE, RN A and CNA E placed used PPE in the resident's trash can in the room.
During an interview on 12/12/23 at 7:45 A.M., CNA F said:
-There was no doffing container in resident's room.
3. Review of Resident #332's admission MDS, dated [DATE] showed:
-Moderate cognitive impairment;
-Dependent for bathing, toileting, dressing, sitting to lying, lying to sitting on side of bed, sitting to standing, and transfers;
-Substantial/maximal assistance when rolling left to right;
-Partial to moderate assistance required for toileting, dressing;
-Supervision or touching assistance for mobility;
-Supervised or touching assistance for personal hygiene;
-Diagnoses included Coronavirus disease (an infectious disease cause by the SARS-CoV-2 virus), generalized muscle weakness, difficulty in walking, cognitive communication deficit (a condition that causes difficulty with thinking and how someone uses language), and need for assistance with personal care.
Resident was admitted on [DATE], no care plan available.
Observation on 12/11/23 at 12:08 P.M. showed a contact precautions container sitting on the floor outside of the resident's room. There was no doffing container found in the room.
Observation on 12/14/23 from 5:18 A.M. to 5:43 A.M. showed the resident remained on isolation precautions. The door to the residents room was open.
During an interview on 12/14/23 at 6:08 A.M., CNA G said:
-The resident refused to have the room door closed;
-When he/she closed resident's room door resident would turn on call light and asked him/her to leave the door open.
During an interview on 12/12/23 at 7:45 A.M., CNA F said:
-He/She had basic training on transmission based precautions during his/her CNA class;
-Facility provided in-services but he/she had not attended any training;
-Donning PPE included applying a gown, mask, face shield, gloves, and shoe protectors. He/She would sanitize before entering resident room and after donning everything;
-When doffing PPE he/she would remove items while in resident room and was about ready to leave;
-Doffing items go into a biohazard bag;
-Often times their were no doffing containers in resident's rooms when residents were on transmission based precautions.
During an interview on 12/12/23 at 8:08 A.M., the Infection Preventionist said:
-He/She had not been providing infection control oversight with the former Director of Nursing (DON) because the DON wanted that task responsibility;
-He/She learned two weeks ago with new Interim DON that the Infection Control task was now back to being his/her responsibility.
-The nurse working was responsible for putting on PPE when a resident tested positive for Covid-19.
During an interview on 12/12/23 at 8:32 A.M., the Infection Preventionist said:
-He/She had Infection Control Certification since he/she started working at facility;
-He/She had not continuously fill infection preventionist role at facility;
-Facility currently had an interim DON and he/she just recently discovered he/she is now responsible for infection prevention oversight;
-He/She believed the Interim DON maintained a spreadsheet of COVID-19 positive residents;
-Residents were on isolation for a full 10 days with the first full day of isolation being counted as day one, which was the day after the positive COVID-19 test;
-When the resident still had symptoms then resident would be in isolation longer than the 10 days;
-The first case of Covid in the facility was 12/3/23;
-He/she began testing on 12/3/23 of staff and residents;
-He/She had no issues obtaining doffing containers;
-He/She was not sure who obtained doffing containers, there was new staff member in central supply who obtained the containers;
-Staff obtained biohazard bags in Central Supply;
-He/She believed housekeeping was responsible for placing biohazard bags in PPE containers outside of rooms;
-He/she knew several rooms did not have doffing containers.
Observation on 12/12/23 at 8:38 AM showed the Infection Preventionist asked RN A if everyone had a doffing container in room. RN A responded that not everyone had one. Housekeeping B asked the Infection Preventionist if housekeeping was supposed to empty trash can and nursing was supposed to take out room trash of COVID positive rooms. Housekeeping B told the Infection Preventionist that he/she was confused and asked if there was trash in trash can in COVID room if he/she needed to take it out. Observation on 12/12/23 at 8:48 A.M. showed Housekeeper B asked Infection Preventionist what he/she did with yellow barrels for residents with Covid.
During an interview on 12/12/23 at 8:52 A.M., Housekeeper B said:
-He/She worked for facility for two years;
-He/She had video training on transmission based precautions and infection control and it was covered at in-services;
-He/She did not know why there was black trash bags tied to closets in a residents room and he/she did not know what to do with resident's dirty clothes;
-He/She thought he/she could placed resident's soiled clothing in a barrel and wheel it down to laundry;
-He/She was unsure on what to do with a Covid outbreak in building;
-Prior to entering Covid positive room, he she had to put on gown, mask, tie gown, apply gloves;
-Prior to leaving Covid positive room he/she would take off gown, then gloves, sanitize hands;
-When he/she cleaned room she uses rag to sanitize door knobs first, then sanitized bed side table;
-He/She would spray down cleaning solution and let it sit for one minute before wiping solution off;
Observation on 12/12/23 at 8:58 A.M. showed Infection Preventionist asking Housekeeper B to locate trash cans and place them outside of covid positive rooms. Housekeeper B then located additional trash cans and placed them on the hall outside the resident room doors.
During an interview on 12/13/23 at 6:21 A.M., CNA D said:
-PPE protocol included first washing his/her hands, applying gloves, then gown, then mask, then shield, and then he/she applied another set of gloves.
-Doffing was to be completed in room by starting with gloves, then gown, then face shield, then mask, and sanitize before leaving room;
-He/She had no issues with doffing containers in rooms;
-He/She had no issues locating PPE;
-He/She did not transport biohazard bags and was unsure who removed those from the resident rooms;
During a continuous observation on 12/14/23 showed:
-At 5:30 AM CNA G went into resident #72's room. He/she did not apply gown and entered resident's room wearing only a mask and gloves. He/she pulled out red biohazard bag from cardboard doffing container and took container to soiled utility room. He/she exited soiled utility room wearing same gloves and did not sanitize.
-At 5:33 A.M. CNA G entered Resident #35's room wearing only gloves and N95 mask. He/she obtained clear plastic trash bag from room and took trash to soiled utility room. He /she exited soiled utility room wearing same gloves.
-At 5:34 A.M. CNA G entered Resident #332's wearing same gloves, did not sanitize or apply gown. He/she removed a red biohazard bag from the room and transported to soiled utility room. Exited room wearing same gloves.
-At 5:35 A.M., CNA G entered resident #48's room wearing same gloves, same mask, did not apply gown or sanitize and removed a black trash bag from room. He/she then took bag to soiled utility room. He/she did not remove gloves, did not sanitize.
-At 5:36 A.M., CNA G knocked on resident #32's room and entered room wearing same gloves had worn in four prior resident rooms. He/she did not apply gown, did not sanitize, and grabbed black trash bag from cardboard doffing container in room. Door to room was left open and CNA G stepped out into hall to obtain an additional black trash bag from doffing supply container. He/she gathered additional trash from resident's bedside trash bag and placed in black trash bag removed from doffing container. CNA G also grabbed an empty cardboard box from room and sat on doffing supply container in hall. CNA G took black trash bag out of room, shut door, and took trash into soiled utility room wearing same gloves as when entering and exiting room.
-At 5:41 A.M. CNA G took new black trash bag into Resident #32's room and placed in doffing container.
During an interview on 12/14/23 at 6:08 A.M., CNA G said:
-He/She had received training on infection control and transmission based precautions;
-When he/she enters Covid positive rooms he/she had to wear gown, gloves, mask, shoe protectors on feet before he/she entered room;
-If he/she had to take things in the room he/she had to leave those items in the room;
-He/She is to wash hands before leaving room;
-When he/she entered Covid rooms and takes trash out he/she is to wash his/her hands or used hand sanitizer;
-Resident who have Covid should have the doors to their room closed to prevent transmission to others;
-When the PPE containers did not have PPE or supplies he/she had no issues finding supplies in other areas of the building;
During an interview on 12/14/23 at 6:49 A.M., Central Supply Coordinator said:
-He/She had no issues obtaining PPE and supplies;
-There was no shortages of PPE in the facility;
-He/She ordered supplies weekly;
-Staff notify him/her when PPE and supplies are needed.
During an interview on 12/14/23 at 4:55 P.M., the Director of Nursing said:
- All employees are to follow infection control guidelines as posted outside resident isolation rooms.
- The Infection Preventionist and charge nurses are to ensure that isolation signage is posted and staff are utilizing PPE appropriately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to ensure they maintained the building in good repair. The facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to ensure they maintained the building in good repair. The facility census was 82.
Observation on 12/11/23 at 4:42 P.M., on 12/12/23 starting at 10:33 A.M., and on 12/13/23 starting at 9:46 A.M., showed:
- Duct tape used to repair the chair in the resident's telephone room;
- The packaged terminal air conditioner (PTAC) unit in the window missing all the knobs and three of the fins broken/missing in room E10;
- A crack in the ceiling around the bathroom light in room E8;
- The exhaust vent had two screws lose and it pulled away from the ceiling half an inch in the bathroom in room E2;
- The bathroom exhaust vent lined with debris in room B22;
- The bathroom exhaust vent lined with debris in room B8;
- Two fins broken/missing on the PTAC unit in room D12;
- The brick corner of the building by the village exit had missing [NAME] that measured an area of one foot by three inches and the other corner on the same side of the building had a two by six inch area of missing bricks.
- Multiple pillars on the outside of the building had missing wood and/or paint.
During an interview on 12/13/23 at 2:14 P.M., the Maintenance Supervisor said all damaged items in the facility needed to be replaced or repaired.
During an interview on 12/12/23 at 11:30 A.M., the Maintenance Supervisor said the housekeeping cleaned everything that did not require a ladder to be cleaned.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen, failed to store food off the floor, failed to label food when it was opened, failed to temperature check foods at food service time, and failed to ensure staff washed their hands when contaminated. The facility census was 82.
Review of facility policy, Food Safety Requirements, undated, showed:
-Food will be stored, prepared, distributed, and served in accordance with professioanl standards for food service safety.
-Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the resident. Elements of the process include the following:
-Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.
-Preparation of food, including thawing, cooking, cooling, holding, and reheating.
-Distribution and service of food to the resident, including transportation, set up, and assistance.
-Equipement used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food.
-Employee hygienic practices.
-Dry food storage - keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pi\pes, and vents;
-Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include:
-Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation;
-Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (when applicable)/discarded; and
-Keeping food covered or in tight containers;
-Holding-staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed.
Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include, but are not limited to:
-Covering all foods when traveling a distance (i.e., down a hallways, to a different unit or floor).
-Using tray lines, mobile food carts or portable steam tables transported to dining areas.
-Washing hands properly before distributing trays.
-Washing hands between contact with residents and after collecting soiled plates and food waste.
-Use of gloves when touchinga nd assisting with ready to eat foods.
-Timely distrubtion of all meals/snacks.
-All equipment used in handling of food shall be cleaned and sanitized, and handled in a manner to pervent contamination
-Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment.
-Clean dishes shall be kept separate from dirty dishes.
-Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils.
-Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.
-Staff shall wash hands according to facility procedures.
-Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas.
-Staff who exhibit a communicable or infectious disease shall be restricted from working in accordance with the facility's work restrictions/infectious diseases policy.
-Dietary staff must wear hair restraints (e.g., hairnet, hat, and /or beard restraint) to prevent hair from contacting food.
-Hairnets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad.
-Staff should maintain nails that are clean and neat, and wearing intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection.
-Gloves will be worn when directly touching ready-to-eat foods and when serving residnets who are on transmission-based precautions. However, staff do not need to wear gloves when distributing foods to resdients at the dining table(s) or when assisting residents to dine unless touching ready to eat food.
1.Observation on 12/11/23 at 10:04 A.M. of the cooler on three tiered cart 1 located outside of the kitchen showed:
-Undated and opened half gallon of chocolate milk;
-Undated and opened 2% reduced fat milk;
-Undated and unlabeled pitchers of juice;
Observation of the entry to the kitchen on 12/11/23 at 10:05 A.M., showed : A beverage cooler sitting on a three tiered cart #2., showed:
-Undated and opened two half gallon containers of chocolate milk;
-Undated and opened thickened lemon water;
-Undated and opened thickened apple juice;
-Unlabeled pitcher of juice;
-Undated and opened 2% gallon of milk
-Dirty plates on second shelf of cart;
-Used sugar packets laying on top
Observation on 12/11/23 at 10:15 A.M. showed:
-In Dry Storage Room: Undated and unlabeled container of fruit loops cereal;
-In the Kitchen:
-Undated and opened imitation vanilla;
-Undated and opened ketchup bottle;
-Undated container of [NAME] salt had powdered sugar written across it;
-Expired bay leaves labeled 9/5/22;
-Undated and opened 41.25 oz container of garlic salt.
During an interview on 12/11/23 at 10:18 A.M., the Dietary Manager said, spices are good for one year.
Observation on 12/13/23 at 10:27 A.M. showed three, three tiered carts in the kitchen with red rubbermaid coolers on them showed:
-Cooler #1:
-Undated and opened milk, ice is melted in cooler;
-Undated and opened thickened lemon water;
-Cooler #2 with Maple written on top:
-Two opened and undated half gallon's of chocolate milk
-Undated and opened 2% milk;
-Undated and opened thickened sweet tea;
-Undated and opened lemon flavored water;
-Cooler #2:
-Undated and opened half gallon of chocolate milk;
-Two undated and opened apple juice containers;
-Undated and opened thickened lemon water container.
Observation of the kitchen on 12/13/23 at 10:32 A.M., showed:
-Opened and undated 32 oz grape jelly;
-Opened and undated 5lb peanut butter tub that was almost empty;
-Opened and undated loaf of wheat bread;
-Undated and unlabeled green plastic storage container contained peanut butter was almost empty, Dietary manager was using it to make peanut butter sandwiches.
Observation on 12/13/23 at 10:41 A.M. showed:
-Refridgerator #2 with:
-Three undated and opened 2% gallon's of milk;
-Undated half gallon of chocolate milk;
-Leftover corn dated 12/10/23 left in the refridgerator;
-Unreadable date on a 12 oz evaporated milk container which was wrapped in dirty plastic wrap.
During an interview on 12/14/23 at 4:24 P.M., [NAME] C said:
-Food should be dated as soon as it is opened and anytime it had to be stored.
During an interview on 12/14/23 at 4:28 P.M., [NAME] A said:
-Food should be dated as soon as it was received and when it was opened.
During an interview on 12/14/23 at 4:44 P.M., [NAME] F said:
-Food should be dated and labeled when received, and when opened;
-Food truck arrives Monday and sometimes Wednesday.
During an interview on 12/14/23 at 4:51 P.M., Dietary Manager said:
-Food should be dated with received date and opened date;
-Leftovers should be thrown away after three days.
2. Observation of dry storage and outside of dietary managers office on 12/11/23 at 10:15 A.M., showed:
-Two boxes of syrup sat directly on floor;
-Two boxes of nectar consistency juice sat on top of syrup;
-One box of rice sat on top of nectar juice;
-One case of pineapple sat on top other box of nectar juice;
-Box of instant food thickener sat on top of rice.
-Case of green beans sat directly on floor outside of mangager's office.
-Case of tomato soup sat on top of green beans outside the manager's office.
-Case of spaghetti sauce sat on top of tomato soup, outside the manager's office.
-Case of red beans sat on top of spaghetti sauce, outside the manager's office.
During an interview on 12/14/23 at 4:24 P.M., [NAME] C said:
-Food should never be stored on floor.
During an interview on 12/14/23 at 4:28 P.M., [NAME] A said:
-Food should never be stored on the floor.
During an interview on 12/14/23 at 4:37 P.M., [NAME] E said:
-Food should not be stored on floor;
-When truck brings food deliveries they drop them off on floor and then dietary staff puts foods up.
During an interview on 12/14/23 at 4:44 P.M., [NAME] F said:
-Food should not be stored on the floor.
During an interview on 12/14/23 at 4:51 P.M., Dietary Manager said:
-Food should be stored six inches off the floor;
-When food deliveres are received from truck they put items on the floor;
-Food truck deliveries come on Monday at 8:00 A.M. but some Mondays it is 10:00 A.M. and Thursdays the time is inconsistent.
3. Review of facility policy, Santation Inspection, dated 9/1/21, showed:
-All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects
-Sanitation inspection will be conducted in the following manner:
a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily
b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.
Observation on 12/11/23 at 10:10 A.M. showed maintenance assist was installing new seal on garbage disposal. There was stacks of dirty pots and pans piled two three tiered carts and there was food service hot boxes with unwashed table service.
During an interview on 12/11/23 at 10:11 A.M., Dietary Manager said:
-The facility garbage disposal had not been working correctly;
-A part was ordered but the disposer was not broken;
-He/She did not use three compartment sink;
-All items stacked in dishwashing area was from most recent meal.
Observation of kitchen on 12/11/23 at 10:34 A.M. with dietary manager present., showed:
-Refridgerator by window had spilled chocolate milk covering the bottom shelf;
-Black three tiered cart by serving line had sticky substances spilled on top shelf, the second shelf had clean napkins stacked next to food crumbs, which included fruit loops, and the bottom shelf had white crumbs on it;
-A black heating fan sat on top of the tableware with clumps of dust particles stuck to wire rim of heater fan;
-Where the tableware heater sat showed spilled brown substance;
-Second three tiered black cart located next to refridgerator had white crumbs scattered about top shelf, the second shelf had a tray with napkin wrapped silverware with additional food crumbs;
-Along the wall by refridgerator #2 showed a broken chair with an additional three tiered cart with crumbs on it;
-The front of steam table showed dried stuck on food.
-Drying racks had visible rust;
-Clean dishes observed on dish rack showed plastic waste wrappers were laying among clean dishes;
-Area underneath sanitation rack for clean dishes was disorganized and dirty with a used foam cup tipped over, pink drinking cup laid on side, a disposable plastic fork laying in a pink tub with several drink cup lids and an opened container of microkill sanitation wipes. Rust was observed on metal shelf;
-Ice machine had brown residue and water droplets down front and outside of unit;
-Top of ice machine had dust residue on it;
-Stacks of dirty dishes were observed on middle and bottom shelf of three tiered food carts.
During an interview on 12/11/23 at 10:38 A.M., Dietary Manager said the ice machine was cleaned one time a month and as needed.
During a continuous obseration on 12/13/23 of kitchen meal preparation showed:
-10:27 A.M., red rubbermaid cooler with sticky substance on top of it sitting at entrance of kitchen on three tiered cart;
-10:30 A.M., a tall pedestal fan sitting on top of crushed ice cooler was covered with caked on dust;
-10:43 A.M., the three tiered cart by steam table had crumbs and food residue on it. Cart also had a box of XL gloves and oven mits laying on top.
-10:45 A.M., dried on red sauce substance stuck to front of steam table;
-10:48 A.M., the drying rack for plate covers had caked on dust and was rusted;
-11:19 A.M., the sahara burst drink machine had a black substance coming out of bottom of the machine;
-11:29 A.M., plate warmer had a small fan caked with dust;
-11:40 A.M., [NAME] B using drink dispenser with black substance to fill up drink pitchers, pitchers were pushed up against black substance;
-11:52 A.M., [NAME] C brought clean silverware and placed on preparation table by steam table. Table had not been sanitized and had spilled ranch dressing laying on table. [NAME] C used a dry towel to wipe off prep table. He/She did not use sanitizer solution to wipe off counter;
-12:20 P.M., A three tiered meal cart used to serve meals in dining room was returned to kitchen after meals were passed and was not sanitized. [NAME] A added new plates to this cart and [NAME] B wheeled unsanitized cart into the dining room. Meal plates were sat directly on cart, no tray was used;
-12:24 P.M., A second three tiered meal cart returned to kitchen from serving meal in dining room and was not sanitized, new food plates were added to cart for meal service. Plates were placed directly on cart;
-12:47 P.M., the sanitizer solution was not changed since observation started at 10:27 A.M.
During an interview on 12/14/23 at 4:28 P.M., [NAME] A said:
-Cleaning checklist is different for each position;
-He/She was responsible for washing stove, steam table, preparation sink, robot coupe, and hand washing sink near kitchen;
-He/She prepped sanitation buckets first thing at 6:00 A.M. in morning then [NAME] C arrived to shift he/she would change them;
-Since COVID was in building facility had used purple sanitizer micro-one wipes, but should use sanitizer bucket water first on food preparation surfaces;
-All food preparation services should be used with sanitizer solution.
During an interview on 12/14/23 at 4:37 P.M., [NAME] E said:
-Cleaning routine included cook cleaning their areas and he/she would clean area around dishwasher ahd mop the floor;
-He/She completed cleaning in morning and at the end of shift;
-Cleaning is completed at end of every meal.
During an interview on 12/14/23 at 4:44 P.M., [NAME] F said:
-Kitchen had a cleaning routine, he/she had a check list that he/she went by;
-Sanitizer buckets are maintained by all staff and should be changed throughout the day;
-Sanitizer bucket should be used when something is spilled.
During an interview on 12/14/23 at 4:51 P.M., Dietary Manager said:
-He/She had daily and weekly cleaning sheets that staff sign off, when completed;
-Cooks rotate cleaning tasks weekly;
-Sanitizer solution was changed every two hours.
4. No policy was provided on dishwashing machine.
Observation on 12/13/23 at 11:14 A.M. of dishwashing machine showed Dietary manager ran test strip that showed 50 parts per million (PPM) which was not within recommended range. Dietary manager primed sanitizer solution and repeated test with new strip which also showed 50 PPM.
During an interview on 12/13/23 at 11:22 A.M., Dietary Manager said:
-He/She primed dishwashing machine sanitizer some more.
Observation on 12/13/23 at 11:22 A.M., showed test strip presented by Dietary Manager was 300 PPM.
During an interview on 12/13/23 at 10:57 A.M., Dietary [NAME] C said:
-He/She had been working in kitchen for 90 days;
-He/She primarily received training from prior jobs with restaurant experience;
-He/She received no formal training when started working in facility kitchen.
During an interview on 12/14/23 at 4:24 P.M., [NAME] C said:
-He/She did not run PPM test on dishwasher, just pushed dishes through dishwasher;
-He/She had no training on use of the dishwasher;
During an interview on 12/14/23 at 4:37 P.M., [NAME] E said:
-He/she tested dishwasher sanitizier PPM in the morning, lunch, and evening and wrote readings on a clip board;
During an interview on 12/14/23 at 4:51 P.M., Dietary Manager said:
-He/She provided inservices to dietary staff when something needs addressed or he/she needed to provide a demonstration to staff;
5. Review of facility policy, Record of Food Temperatures, undated, showed:
-It is policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature before trays are assembled.
-Food temperatures will be checked on all items prepared in the dietary department.
-Hot foods will be held at 135 degrees Fahrenheit or greater.
-Hot foods will be stirred during holding to redistribute heat throughout the food product.
-Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit.
-Food containers will be kept covered to retain heat and prevent environmental contaminants from entering the food.
-Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log.
-When holding hot foods for service, food temperature should be measured when placing it on the steam table line.
-If the food temperature falls into an unsafe range, immediately follow procedures for reheaing previously cooked food.
-Potentially hazardous food that is cooked and cooled must be reheated so that all parts of the food reach an internal temrpature of 165 degrees F for at least 15 seconds before holding for hot service.
-Ready to eat foods that require heating before consumption should be taken directly from a sealed container or an intact package from an approved food processing source and heated to at least 135 degrees F for holding for hot service.
-No food will be served that does not meet the food code standard temperatures.
-Food will not be cooked or reheated using the steam table because it does not bring food to the proper temperature within acceptable timeframes.
-Place cold menu items such as ham salad or egg salad over an ice bath in a pan (preferably on a separate cart) and not beside a heated steam table.
-Food temperatures wil be verified using a thermometer which is both clean, sanitized, and calibrated to ensure accuracy.
Observation on 12/11/23 at 10:34 A.M. of food temperature logs showed only one temperature being documented of food temperatures at meal time.
During an interview on 12/11/23 at 10:36 A.M., Dietary Manager said temperatures should be taken when the cook had completed cooking. The temperature documented in the log was the temperature from the time of food service.
During a continuous observation on 12/13/23 of kitchen meal preparation showed:
-10:32 A.M., the food temperature logs from breakfast had only one temperature recorded which included:
-180 degrees for hot cereal;
-170 degrees for pureed cereal;
-176 degrees for cheese omelet;
-172 degrees pureed #10;
-174 degrees plain omelet;
-174 degrees plain egg sub omelet;
-38 degrees whole milk;
-140 degrees coffee.
-10:36 A.M., temperature logs on refridgerator #1 & #2 were completed in advance for the next day of 12/14/23 with log showing refridgerator #1 (36 degrees) and refridgerator #2 (37 degrees). The logs showed on 12/13/23 the evening shift had already recorded in advance of evening shift the refridgerator #1 (40 degrees) and refridgerator #2 (38 degrees).
-10:59 A.M., Dietary Manager pulled chicken out of oven and sat on edge of steam table. Fried chicken observed to be at 184 degrees. Cleaned thermometer then checked a drumstick which food temperatured checked at 192.3. Placed in oven.
-11:02 A.M., Dietary manager logged food temperature on green page in menu/food temperature book. Second pan of chicken obtained from oven using oven mits. Thermometer stuck in chicken and read 206.7 degrees. Drumstick was tested at 189.1 degrees. Third pan of chicken obtained from oven.
-11:22 A.M, Dietary [NAME] A poured water into steam table;
-11:22 A.M., Pan #2 of chicken remained uncovered since being temped at 11:02 A.M.
-11:26 A.M., Dietary [NAME] A placed peas and carrots on steam table.
-11:26 A.M., Pan #1 of chicken was added to steam table from oven, not temped since cooking temperature taken at 10:59 A.M.
-11:27 A.M., Pureed food containers from oven added to steam table, they were not temped.
-11:36 A.M., Dietary Manager temped carrots and peas on steam table at 186 degrees.
-11:39 A.M., Dietary Manager temped baked chicken at 148 degrees, then placed baked kitchen back on stove top for further cooking;
-11:39 A.M., [NAME] A made instant potatoes adding hot water from tea dispenser and whisked together;
-11:41 A.M., Dietary Manager temped mashed potatoes at 155.6 degrees and told [NAME] A they needed to be cooked longer;
-11:45 A.M., Baked chicken was retemped at 171.5 degrees;
-11:47 A.M., Pureed chicken temped at 179 degrees;
-11:49 A.M., Pureed peas and carrots temped at 172 degrees;
-11:50 A.M., Shredded chicken temped at 171 degrees;
-12:01 P.M., Mashed potatoes temped at 207 degrees and placed on steam table;
-12:04 P.M., Hamburger patties temped at 168.8 degrees and placed on steam table;
-12:07 P.M., Gravy temped at 203 degrees and placed on steam table;
-12:13 P.M., [NAME] A plated first meal;
-12:15 P.M., first cart served to dining room;
-12:46 P.M., Observed temperatures written on a paper towel showed carrots and peas 186 degrees, baked chicken 171.9 degrees, peas and carrots 178 degrees.
-12:59 P.M., [NAME] C placed container of soup in microwave to warm up, then removed from microwave and handed to [NAME] A and was placed on food service tray. Soup was not temped.
-1:36 P.M., Food temperatures on test tray showed mashed potatoes 144.2 degrees, carrots and peas 140.8 degrees, chicken at 133.7 degrees, and fruit at 49.8 degrees.
During an interview on 12/14/23 at 4:28 P.M., [NAME] A said:
-Food should be temperature checked when came out of oven and before serving it;
-He/She did not check food temperatures on 12/13/23 after food was on steam table because he/she served right after taking it out of oven;
During an interview on 12/14/23 at 4:44 P.M., [NAME] F said:
-Food should be temperature checked when prepared, when food is served, and right before put on serving table;
During an interview on 12/14/23 at 4:51 P.M., Dietary Manager said:
-Food should be temperature checked right out of the oven;
-Food did not need to be temped it when taking it right out of the oven and placed directly on steam table for food service;
-Food should not be on steam table within thirty minutes of service;
-After serving food the food should be temperature checked again;
6. Review of facility policy, Handwashing Guidelines for Dietary Employees, undated, showed:
-Handwashing is necessary to prevent the pread of bacteria that may cause foodborne illnesses. Dietary empoyees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, warewashing, or in a service sink used for the disposal of mop water or similar waste.
-Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations:
-Every time an emplyee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet.
-After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc.
-After hands have touched bare human body parts other than clean hands, such as face, nose, hair, etc.
-After coughing, sneezing, or blowing your nose, using tobacco, eating or drinking.
-After handling chemicals and before beginning to work with food.
-While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.
-When switching between working ith raw food and working with ready to eat food.
-Before donning gloves for working with food.
-After engaging in any activity that may contaminate the hands.
Continuous obseration on 12/13/23 of kitchen meal preparation showed:
-10:32 A.M., [NAME] C entered kitchen did not wash hands, began to apply gloves. Dietary supervisor told [NAME] C he/she needed to wash hands. He/she did not have on hair net.
-10:37 A.M. [NAME] C washed hands, applied mask, then applied hairnet. He/She did not wash hands after applying hair net;
-11:15 A.M., [NAME] A touched trash can lid when threw away gloves then took foil off peas and carrots that were on stove. He/She did not wash hands after touching trash can.
-11:48 A.M., [NAME] D entered kitchen, did not wash hands, did not have on hair net, laid apron on food preparaton table;
-11:51 A.M., [NAME] D washed hands, applied his/her apron, name tag, and face mask. His/Her phone started ringing so he/she went to dry storage room to answer phone. Exited storage room, did not wash hands. Touched his/her apron and began food preparations;
-11:52 A.M., [NAME] C ran dirty dishes through sanitizer, did not wash hands, then grabbed clean silverware from clean side of dishwasher and placed on preparation table by steam table. The table had not been sanitized and had spilled ranch dressing laying on table. [NAME] C used a dry towel to wipe off prep table. He/She did not use sanitizer solution to wipe off counter;
-11:54 A.M., [NAME] C cleaned off preparation table with a dry towel, did not wash hands. He/She then applied gloves and wrapped up silveware. He/She touched face mask to pull down mask to talk to [NAME] B. He/She did not wash hands and continued wrapping silverware with napkins;
-11:58 A.M., showed [NAME] B be left kitchen. He/She returned to kitchen and did not wash hands. He/She then obtained clean scoops from sanitizer placed on prep table across from stove. [NAME] B grabbed scoops with unwashed hands and placed them on prep table. The prep table still had food crumbs on it had not been sanitized;
-12:00 P.M., [NAME] D entered kitchen and did not wash hands;
-12:05 P.M., Dietary manager entered kitchen did not wash hands, 12:10 P.M. observed slicing bread with unwashed hands;
-12:15 P.M., Dietary Manager and [NAME] D exited kitchen and re-entered kitchen at 12:16 P.M. and both did not wash hands. Dietary manager grabbed items from box. [NAME] D grabbed clean rolls of silverware from [NAME] B to take to dining room;
-12:44 P.M., [NAME] C went from loading dirty dishes into dishwasher, then handed peanut butter and jelly sandwishes for [NAME] A. He/She did not wash hands;
Cook C touched nose of mask, did not wash hands, went into dry storage and grabbed crackers to hand to [NAME] A. [NAME] C then assembled hamburgers by adding lettuce, onion, and tomato to meat patty. [NAME] C then made grilled cheese sandwiches on stove top.
During an interview on 12/14/23 at 4:24 P.M., [NAME] C said:
-He/She should wash hands when entered kitchen and in between tasks;
-He/She should wash hands after loading dirty dishes and before putting away clean dishes from dishwasher.
During an interview on 12/14/23 at 4:28 P.M., [NAME] A said:
-Handwashing should be done anytime he/she changed stations from one activity to the next.
During an interview on 12/14/23 at 4:37 P.M., [NAME] E said:
-He/She must wash hands all the time;
-He/She washed hands when first entered kitchen, after touching face, and between cleaning dirty dishes and putting away clean dishes.
During an interview on 12/14/23 at 4:44 P.M., [NAME] F said:
-Hands should be washed every time he/she changed stations, if he/she prepped meat then moved to go to the fridge he/she should wash hands first;
-He/She washed hands when dealing with raw vegetables.
During an interview on 12/14/23 at 4:51 P.M., Dietary Manager said:
-He/She expected staff to wash hands when they come in to kitchen, then apply hair nets, then see what their tasks are for the day, and go wash their hands again;
-Staff should was their hands after they touch their face, their masks, before applying and after removing gloves, and after they go to the restroom.
During an interview on 12/14/23 at 5:22 P.M., the Director of Nursing said:
-He/She expected whole team to be responsible for gathering dirty dishes after meals;
During an interview on 12/14/23 at 5:22 P.M., the Administrator said:
-Food should not be stored on the floor;
-Dietary should be washing their hands before, after, and between dirty to clean;
-There was not sufficient plates in facility;
-Food should be labeled and dated when it was opened;
Jul 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to do a thorough investigation and follow their policy when the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to do a thorough investigation and follow their policy when the facility reported resident to resident altercations to the state agency, when four sampled residents (Residents #1, #2, #3, #4) were involved in resident to resident altercations. The facility census was 85.
Review of the facility Abuse, Neglect, and Exploitation policy, dated 9/1/2021, showed:
-It is the policy of the this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
-V. Investigation of Alleged Abuse, Neglect, and Exploitation
-A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.
-B. Written procedures for investigations include:
1. Identifying staff responsible for the investigation;
2. Exercising caution in handling evidence that could be used in a criminal investigation;
3. Investigating different types of alleged violations;
4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator,
witnesses, and others who might have knowledge of the allegations;
5. Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred,
the extent, and the cause;
6. Providing complete and thorough documentation of the investigation.
-VI. Protection of Resident
The facility will make efforts to ensure all residents are protected from physical and psychological harm during and after the investigation. Examples include but are not limited to:
A. Responding immediately to protect the alleged victim and integrity of the investigation;
B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;
C. Increased supervision of the alleged victim and residents;
D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;
E. Protection from retaliation;
F. Providing emotional support and counseling to the resident during and after the investigation, as needed.
1. Review of Resident #1's quarterly Minimum Data Set, a federally mandated assessment conducted by staff, showed:
-Diagnoses of bladder cancer, vascular dementia with behaviors (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), mood disorder (a class of serious mental illnesses, describing all types of depression and bipolar disorders), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder, and psychotic disorder with delusions.
-He/She is usually able to make self understood and usually understands others.
-Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 3. This score indicates severely impaired cognitive functioning.
-Behaviors including delusions and wandering.
-He/She requires supervision for all activities of daily living.
Review of the resident's comprehensive care plan, dated 3/14/23, showed:
-He/She is an elopement risk/wanderer, paces on the secure unit, goes in and out of peer's rooms taking food items off of peer's trays, pulling pants down and walking in common areas.
-He/She has potential to be physically aggressive towards others related to poor impulse control. He/She had a physical altercation with another resident on July 20, 2023 and July 22, 2023.
2. Review of Resident #2's quarterly MDS, dated [DATE], showed:
-Diagnoses of dementia with behaviors (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities), mild cognitive impairment, restlessness and agitation, viral Hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), mood disorder, personality disorder, psychosis.
-He/She usually understands others and can usually make self understood.
-BIMS score of 4. This score indicates severely impaired cognition.
-He/She needed supervision for all activities of daily living.
Review of the resident's comprehensive care plan, dated 5/3/2023, showed:
-He/She has physical outbursts towards others when upset and/or frustrated.
-He/She had physical altercations with peers on 10/9/2022, 4/5/2023, 7/24/2023, and 7/25/2023.
3. Review of Resident #3's significant change MDS, dated [DATE], showed:
-Diagnoses of dementia with agitation, Type 1 Diabetes (a chronic condition in which the pancreas produces little or no insulin), heart failure (occurs when the heart muscle doesn't pump blood as well as it should).
-He/She is able to understand others and usually able to make self understood.
-BIMS score of 12. This score indicates moderately impaired cognition.
-He/She requires supervision to extensive assistance with all activities of daily living.
Review of the resident's comprehensive care plan, dated 4/14/2023, showed:
-The resident wanders and is an elopement risk.
-The resident receives psychotropic medication for the disease process of dementia with agitation and anxiety.
4. Review of Resident #4's quarterly MDS, dated [DATE], showed:
-Diagnoses of bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)), dementia, alcohol dependence, chronic pain. major depressive disorder, alcohol induced psychotic disorder (symptoms of psychosis present during or shortly after heavy alcohol intake), anxiety, falls.
-He/She is able to understand others and make self understood.
-BIMS score of 15. This score indicates no cognitive impairment.
-He/She requires supervision to limited assistance with all activities of daily living.
Review of the resident's comprehensive care plan, dated 5/17/2023, showed:
-He/She has behaviors with history of trying to run staff over with wheelchair, yelling/screaming/cursing at staff, refusing care, sneaking alcohol into the facility, making false accusations against staff, cutting roommate's cell phone charging cord, physical altercations with other residents.
5. Review of the facility's investigation regarding the physical altercation where Resident #1 hit Resident #2 on 7/20/2023 showed:
-No record of staff interviewing Resident #2 regarding the incident.
-No record of other residents in the facility being interviewed regarding their observations or feelings of safety.
-No record physician was notified of incident.
-No record local law enforcement was notified of incident.
Review of the facility's investigation investigation regarding the physical altercation when Resident #3 hit Resident #1 on 7/21/2023, after Resident #1 wandered into Resident #3's room showed:
-No record of staff interviewing resident #1 regarding the incident.
-No record of staff interviewing other residents in the facility regarding the incident or feelings of safety.
-No record of local law enforcement was notified of the incident.
Review of the facility's investigation regarding the physical altercation when Resident #1 hit Resident #4 in the back of the head on 7/25/2023, showed:
-No record other residents in the facility were interviewed regarding the incident or their feelings of safety in the facility.
During an interview on 7/28/23 at 11:30 A.M., the Social Worker said:
-He/She was not employed at the facility when some of these resident to resident altercation occurred.
-He/She is aware that other residents in the facility should be interviewed for their feelings of safety.
-Residents on the locked unit were not interviewed after altercations occurred because they are not cognitively able to be interviewed.
During an interview on 7/28/23 at 11:35 A.M., the Administrator said:
-He/She was unaware that other residents in the facility were not interviewed after each resident to resident altercation.
-Other resident should be interviewed for their feelings of safety after an altercation or incident occurs.
MO221778
MO221846
MO221951
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to maintain a safe, functional, sanitary and comfortable environment by failing to replace broken and/or missing panes of glass in windows on th...
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Based on observation and interview, the facility failed to maintain a safe, functional, sanitary and comfortable environment by failing to replace broken and/or missing panes of glass in windows on the secure community and ensuring the air conditioning units on the secure community remained securely and safely covered. The facility census was 85.
The facility did not provide a policy related to safe/functional/sanitary/comfortable environment.
Observation of the facility's secure community on 7/27/23 at 2:07 P.M., showed:
-In Room E11, a large piece of cardboard taped over a window with multiple missing and/or broken panes of glass.
-In Room E12, cardboard taped over window missing panes of glass. There are multiple pieces of broken glass between the cardboard and the window screen.
-In Room E13, cardboard taped over five missing panes of glass. There are 2 broken panes of glass in this window as well.
-In Room E20, there are three beds in the room. The air conditioning unit cover is off of the unit and laying on one of the beds. The unit has exposed wires. Cardboard is taped over a window with multiple missing/broken panes of glass. The door to the room is open to the hall. During this observation, two residents were observed wandering past Room E20 multiple times, stopping to look into the room, then walking on.
During an interview on 7/27/23 at 2:18 P.M., Certified Nurses Aide A said:
-The cardboard has been covering the windows for over two months.
-Around two months ago, there was a resident who was breaking out the windows, trying to get out. That resident no longer lives at the facility.
-Maintenance taped the cardboard over the window.
-He/She was not aware the air conditioning unit cover was off of the unit in Room E20.
During an interview on 7/27/23 at 2:24 P.M., Certified Medication Technician A said:
-The windows have been broken for at least two months.
-He/She is unaware how they were broken.
During an interview on 7/28/23 at 11:20 A.M., the Maintenance Director said:
-He/She is aware there are broken/missing panes of glass, covered by cardboard in rooms on the secure community.
-He/She was unaware that the air conditioning unit cover was off in Room E20.
-A resident who frequently wanders the unit has a history of taking off the air conditioning unit covers.
During an interview on 7/28/23 at 11:33 A.M., the Administrator said:
-He/She was aware that there are broken/missing panes of glass, covered by cardboard, in windows on the secure community.
-They were broken approximately four weeks ago. He/She believes new windows needed to be ordered to replace the broken windows.
-He/She was unaware the cover the to air conditioning unit was off. He/She thought that Room E20 was to be closed off so residents could not enter the room.
MO221789
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to maintain a comfortable environment when the facility grounds were not mowed and maintained. The grass had headed out and wa...
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Based on observations, interviews, and record review, the facility failed to maintain a comfortable environment when the facility grounds were not mowed and maintained. The grass had headed out and was approximately eighteen inches tall. Facility census was 84.
Review of facility policy, Grounds, dated May 2021, showed:
-Facility grounds shall be maintained in a safe and attractive manner;
-Maintenance shall be responsible for keeping the grounds free of litter;
-Lawns shall be mowed on a weekly or bi-weekly basis during the grass cutting season.
- Shrubs shall be trimmed as needed:
-Areas around the buildings shall be maintained in a safe and orderly manner at all times.
Observation on 5/23/23 at 9:00 A.M. showed:
-Facility grounds had not been mowed;
-The grass was headed out and approximately eighteen inches tall;
-The grass was overgrown.
During an interviews on 5/23/23 at 1:15 P.M. and 1:20P.M. the Administrator in training (AIT) said:
-The maintenance department was responsible for the lawn;
-There used to be a lawn service that maintained the lawn that ended about a month or so ago;
-He/she expected the lawn to be mowed weekly or bi-weekly; as needed to maintain;
-The lawn was last mowed two weeks ago;
-The facility did not have a weedeater in house;
-The facility was purchasing a weedeater.
During an interview on 5/23/23 at 1:20 P.M. the Maintenance Director with the Administrator present, said:
-The facility was in between lawn companies;
-Corporate staff was responsible currently for mowing;
-The lawn was last mowed ten days ago;
-He/she expected the lawn to be mowed every seven to ten days;
-Last year the lawn company was mowing every ten to fourteen days.
MO218403
Feb 2023
3 deficiencies
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a comfortable home-like environment when they failed to exerc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a comfortable home-like environment when they failed to exercise reasonable care for the protection of resident's property from loss or theft. This impacted three of three surveyed residents (Residents #11, #12 and #10) The facility census was 87.
Review of the facility's policy, Resident Personal Belongings, dated 9/1/21, showed:
-It is policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishing for their use while in the facility and assure the personal belongings and/or possession are rightfully returned to the resident, or to the resident's representative in the event of the resident's death or discharge from facility;
-All resident's possessions, regardless of their apparent value to others, will be treated with respect;
-The facility will support the resident's right to retain and use personal possessions to promote a homelike environment and maintain their independence;
-All resident personal items will be inventoried at the time of admission and documentation shall be retained in the medical record;
-Additional possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory list;
-The facility will exercise reasonable care for the protection of the resident's property from loss or theft.
1. Review of Resident #11's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 1/10/23, showed the resident is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15.
During an interview on 2/3/23 at 10:00 A.M., the resident said:
-He/she has lost quite a bit of clothing that has not returned from laundry services;
-He/she no longer trusts sending clothes to laundry for washing;
-He/she has two bags of clothes for family to do the laundry;
-He/she is scared clothes will come up missing again;
-He/she previously told the prior Administrator, prior Director of Nursing (DON), and prior Assistant Director of Nursing (ADON) about concerns.
2. Review of Resident #12's quarterly MDS, dated [DATE], showed the resident is cognitively intact with a BIMS score of 14.
During an interview on 2/3/23 at 11:55 A.M., the resident said:
-He/she has lived in the facility for four years;
-Family brought nineteen new nightgowns at Christmas and about half are missing;
-All items were marked with his/her name;
-A grievance was filed and laundry notified;
-Laundry unable to locate personal items.
3. Review of Resident #10's MDS showed no MDS was completed.
Review of the resident's care plan, dated 10/19/22, showed:
-admitted [DATE];
-Diagnoses include muscle weakness and arthritis
During an interview and observation on 2/3/23 at 10:00 A.M., the resident said and showed:
-He/she did not trust sending personal clothes to laundry; it is washed in hot water and shrinks;
-His/her clothes need to be washed in cold water;
-He/she wore facility gowns now due to fear of personal items being ruined in laundry;
-Resident observed wearing hospital gown;
-He/she had notified laundry and written grievance.
4. Review of the facility grievance log from 11/1/22 to 1/31/23 showed:
-11/28/22 Resident stated that he/she does not always get clothes back from laundry. Resident unable to give any specifics of what items were missing. Resolution was laundry staff will keep eye out for this resident's clothes in other resident's closets;
-12/15/22 Resident #11 missing black pants, dark gray flannel t-shirt, gray sweat suit top and bottom, V-neck KC Chiefs t-shirt, pink [NAME] t-shirt, public enemy t-shirt, and black sweater all with names on items; there was no documented resolutions on complaint/grievance report;
-12/28/22 Resident stated missing two pairs of jeans, one pair hospital pajama pants, two black t-shirts, one dark blue t-shirt, four pairs of white long calf socks, one brown hoodie jacket; there was no documented resolutions on complaint/grievance report;
-12/29/22 Resident #11 lost gray sweat pants with seams down the leg and yellow knit shorts; there was no documented resolutions on complaint/grievance report;
-12/29/22 Resident missing several pairs of underwear that are specific for religion. He/she stated often gets other resident's clothes. Notes stated looking for his/her underwear. Resident stated he/she was going to order more underwear;
-1/3/23 Resident stated he/she is missing two pairs of jeans, six t-shirts, and frequently does not get his/her laundry back. Findings showed four t-shirts and one pair of jeans were found.
During an interview on 2/3/23 at 11:52 A.M., the Social Services Director said:
-He/she maintained the grievance logs and gave concerns to department heads;
-He/she and staff look for missing items and follow up with resident;
-Facility replaces missing items if they are not located;
-Resolutions are written on the bottom of grievance forms.
During an interview on 2/3/23 at 3:12 P.M., the Laundry Tech said:
-Dirty laundry is collected, washed, and hung up in an area designated for each resident, then passed back to residents;
-Clothes have names on them;
-If clothes are lost we look for them;
-If we cannot locate clothes then they are replaced.
During an interview on 2/3/23 at 3:17 P.M., the Administrator said:
-The facility replaces items they cannot find;
-Certified Nurses Assistants (CNA) put resident names on their belongings upon arrival.
During an interview on 2/3/23 at at 3:18 P.M., activities staff said resident items are initialed upon admission.
During an interview on 2/3/23 at 3:44 P.M., the Laundry Aide said:
-He/she tries to locate missing laundry;
-There is a cart in the corner of the laundry room of stuff that does not have names on it;
-He/she receives grievance papers on items that are lost.
During an interview on 2/3/23 at 4:44 P.M. Administrator said:
-He/she expected laundry and nursing staff to search rooms for resident's missing items;
-If laundry cannot locate items, facility will discuss missing items and facility will replace the missing items;
-He/she was not aware of any trends with missing items in laundry.
MO213192
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received the necessary services to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received the necessary services to maintain good grooming and personal hygiene when showers were not provided and did not let residents choose shower preferences which affected eight residents (Resident #10, #11, #12, #13, #14, #15, #16, and #17), and staff failed to provide shaving for three dependent residents (Resident #13, #14, & #17). The facility census was 87.
Review of the facility's policy, Resident Showers, dated 9/1/21, showed:
-It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice;
-Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety;
-Partial baths may be given between regular shower schedules as per facility policy.
Review of the facility's policy, Grooming A Resident's Facial Hair, dated 9/1/21, showed it is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice.
1. Review of Resident #10's record showed no Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), was completed.
Review of the resident's care plan, dated 11/16/22, showed:
-Resident is extensive assist of two staff to provide bath/shower as necessary;
-Resident requires limited assistance by one staff to turn and reposition in bed;
-Diagnoses include muscle weakness, arthritis, and dual incontinence.
Review of the shower schedule on 2/3/23 at 11:30 A.M., showed the resident's showers were scheduled on Tuesday evening and Friday evening.
Review of shower sheets from 12/17/22 to 2/3/23 showed no showers completed.
During an observation and interview on 2/3/23 at 10:00 A.M., Resident #10 said:
-He/she has not had a shower in two months;
-Showers were brought up by multiple residents at a recent meeting held by the new administrator;
-He/she has received only three showers since October.
-The resident's hair was greasy;
-The resident's skin was dry and flaky;
-He/she washed himself/herself in the sink.
2. Review of Resident #11's quarterly MDS, dated [DATE], showed:
-Brief Mental Status (BIMS) score of 15, resident is cognitively intact;
-Resident required bathing assistance;
-Mobility devices used include walker and wheelchair;
-One person physical assist for bed mobility, transfers, dressing, and toilet use. Required set up help for personal hygiene;
-Diagnoses included arthritis (a condition resulting in painful inflammation and stiffness of joints).
Review of the resident's care plan, dated 1/16/23, showed that resident has an activities of daily living (ADL) self-care performance deficit and needs moderate to maximum assist with bed mobility, transfers, needs assistance with activities of daily living, and frequently incontinent of urine.
Review of the shower schedule showed the resident's showers were scheduled on Tuesday evenings and Friday evenings.
Review of shower logs showed resident had no shower sheets completed in past two months.
During an observation and interview on 2/3/23 at 10:00 A.M., the resident said:
-He/she has not had a shower or bath in two months;
-He/she gave himself/herself baths in the sink to prevent having body odor.
-Resident's hair was matted and wiry
3. Review of Resident #12's care plan, dated 8/10/22, showed:
-Prefers to bathe three times a week;
-Receives total assist with two people for showers
Review of the resident's quarterly MDS, dated [DATE], showed:
-BIMS score of 14, cognitively intact;
-Resident requires two person physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene;
-Resident is dependent with showering;
-Diagnoses include left knee prosthesis, diabetes, muscle weakness, arthritis, and overactive bladder;
-Uses motorized wheelchair and mechanical lift.
During an interview and observation on 2/3/23 at 12:00 P.M., the resident said and showed:
-He/she does not get showers;
-It has been five weeks since he/she had a shower in the facility;
-His/her last shower was three weeks ago in the hospital;
-He/she prefers to shower at least two times a week;
-The resident had greasy hair.
Review of the shower logs showed the resident did not receive a shower for two months.
4. Review of Resident #13's care plan, dated 9/17/22, showed:
-Prefers to bathe twice a week;
-Shaving assistance: Staff to complete task on shower days.
Review of the resident's quarterly MDS, dated [DATE], showed:
-BIMS score of 15, resident is cognitively intact;
-Requires one person physical assist with personal hygiene;
-Resident requires physical help limited to transfer only when bathing, and supervision or touching assistance;
-Mobility devices include a walker and wheelchair.
During an interview and observation on 2/3/23 at 9:35 A.M., the resident said and showed:
-He/she does not get showers two times a week;
-He/she has not had a shower this week;
-He/she cannot remember the last time he/she had a shower;
-It has been a while since staff helped him/her shave;
-A quarter inch of facial hair on the chin;
-He/she did not like having long chin hair.
Review of the shower schedule showed the resident's shower days were scheduled Wednesday and Saturday.
Review of the shower logs from 12/17/22 to 2/3/23 showed:
-The resident has not received showers twice per week as preferred;
-The resident received one shower a week;
-The resident did not receive a shower during the week of 1/15/23.
5. Review of Resident #15's care plan, revised 11/11/2022, showed the resident required assistance by (1) staff with showering twice weekly and as necessary.
Review of the resident's annual MDS, dated [DATE], showed:
-BIMS score of 13, cognitively intact;
-Personal hygiene requires supervision, oversight, encouragement, or cueing;
-Bathing requires supervision oversight help only;
-No behavior regarding rejection of care;
-Diagnoses included arthritis, muscle weakness, mood disorder, alcohol dependence with withdrawal delirium, difficulty in walking.
Review of shower logs from 12/17/22 to 2/3/23 showed:
-Resident did not receive showers twice weekly per care plan preferences;
-Resident received no showers in December from 12/17/22 to 12/31/22;
-Resident received one shower in January on 1/18/23;
-Resident refused two offered showers in January on 1/16/23 and 1/23/23.
Review of complaint logs from 11/1/22 to 1/31/23 showed:
-12/29/22 Resident stated he had not received shower in seven days and refused to be showered by a female.
During an interview and observation on 2/3/23 at 9:08 A.M., the resident said and showed:
-He/she has not had a bath/shower since last week;
-The resident smelled of urine;
-The resident's hair was stringy and greasy.
6. Review of Resident #16's care plan, dated 8/1/22, showed:
-Provide sponge bath when a full bath or shower cannot be tolerated;
-Resident requires extensive assistance with one person assist with showers twice a week & PRN (as needed).
Review of the resident's quarterly MDS, dated [DATE], showed:
-BIMS of 8, moderately impaired cognition;
-Diagnoses included: unspecified dementia, difficulty in walking, pain in left knee, age related physical debility, spinal stenosis of cervical region and lumbar region (a narrowing of the spinal canal that can cause pain, numbness, muscle weakness, and impaired bladder or bowel control), history of falling, macular degeneration (an eye disease that causes vision loss);
-Required substantial staff assistance with bathing.
During an interview on 2/3/23 at 9:35 A.M., the resident said:
-His/her last shower was on Monday 1/30/23;
-He/she does not refuse showers;
-He/she is only showered once a week.
Review of the shower logs showed:
-The resident did not receive showers twice a week;
-The resident received one shower a week;
-The resident did not receive a shower the week of 1/15/23;
-No sponge baths documented.
7. Review of Resident #14's care plan, dated 4/29/22, showed:
-Prefers to bathe once a week;
-Shave on shower days;
-Resident requires assistance by one staff for showering twice weekly as necessary.
Review of the resident's quarterly MDS, dated [DATE], showed:
-BIMS score of 14, resident is cognitively intact;
-Requires extensive assistance with one person physical assist with personal hygiene;
-Requires one person physical assist with bathing; substantial/maximal assistance;
-Mobility devices include a wheelchair;
-Diagnoses included: diabetic neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), muscle weakness, and need for assistance with personal care.
Review of the shower logs showed:
-The resident did not receive showers twice a week;
-The resident received one shower a week;
-No showers completed the weeks of 1219/22 and 1/23/23.
During an interview and observation on 2/3/23 at 9:32 A.M., the resident said and showed:
-He/she wanted to be shaved;
-Staff do not help shave;
-He/she felt dirty when he/she was not shaved;
-A half inch of hair growth on his/her chin and cheeks.
8. Review of Resident #17's care plan, dated 10/24/22, showed:
-Potential for ADL self-care performance deficit due to decreased vision and chronic pain;
-Prefers only one shower a week in the afternoon;
-Will only take shower with certain bath aide;
-Prefers to shave daily with electric razor.
Review of the resident's quarterly MDS, dated [DATE], showed:
-BIMS score of 15, showed cognitively intact;
-Physical help in bathing activity;
-Supervision oversight, encouragement and cuing required for personal hygiene;
-Diagnoses included chronic pain syndrome, legal blindness, and need for assistance with personal care.
During an interview and observation on 2/3/23 at 9:45 A.M., the resident said and showed:
-He/she got showers once a week, but would like two times a week;
-His/her hair was long, greasy looking, and unwashed.
Review of the shower schedule showed the resident was scheduled for showers on Tuesdays during the day.
Review of the shower logs showed:
-The resident received one shower a week;
-The resident did not receive a shower on the following weeks: 12/19/22, 12/26/22, 1/23/23, and 1/30/23.
During an interview on 2/3/23 at 11:40 A.M., Licensed Practical Nurse (LPN) A said shower logs were turned in daily to the Director of Nursing (DON).
During an interview on 2/3/23 at 11:45 A.M., Certified Nurse Aide (CNA) A said:
-The shower on Maple was not working on the far end of the hall;
-Shower refusals were written on the shower sheet as refused;
-Another staff does not attempt to shower residents who refused.
During an interview on 2/3/23 at 3:24 P.M., CNA B said:
-Residents who refuse were asked to sign the shower sheet;
-Showers were offered by nurses if a resident refused;
-Showers should occur twice weekly for all residents.
During an interview on 2/3/23 at 3:33 P.M. CNA C said:
-Shaving was provided at every shower;
-Residents receive showers twice a week;
-Second shift showers begin at 6:00 P.M.
During an interview on 2/3/23 at 3:54 P.M., the DON said:
-He/she started working in the facility on 1/9/23;
-He/she expected men to be shaved in the shower and as needed;
-He/she expected women to be shaved in the shower and documented on the shower sheet;
-He/she expected residents to be shaved as requested or as needed;
-Social services or activities determines resident shower preferences at intake;
-Resident shower schedules should be made according to resident routine prior to arriving to facility;
-He/she expected staff to provide showers at least twice a week;
-He/she expected staff to have residents sign shower sheets if they refuse;
-Staff should offer an additional shower opportunity to those who refuse and have a different staff member ask the resident;
-Shower refusals should be documented in the communication log at nurses' station;
During an interview on 2/3/23 at 4:44 P.M., the Administrator said:
-Showers should be done according to the resident's preference;
-Most residents choose to receive showers twice a week;
-Some residents only want certain staff to provide showers to them;
-Refused showers should be offered to resident on another day or shift;
-Shower preferences should be documented in residents care plan;
-Shaving should be completed as needed for each resident;
-Residents should be shaved, groomed, and presentable;
-Grooming should occur daily;
-Shaving should occur right after the shower for resident's with facial hair.
MO213192
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 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 interview, the facility failed to provide food and drinks that were palatable, attractive, and at a saf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide food and drinks that were palatable, attractive, and at a safe and appetizing temperature when hall trays were not served at a safe and appetizing temperature which affected three of six sampled residents (Resident #10, #11, #12) and drinks were served at room temperature with no ice which affected four of six sampled residents (Resident #10, #12, #15, #16). The facility census was 87.
Review of the facility policy, Record of Food Temperatures, dated 9/1/21, showed:
-It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled
-Food temperatures will be checked on all items prepared in the dietary department;
-Hot foods will be held at 135 degrees Fahrenheit or greater;
-Hot foods will be stirred during holding to redistribute heat throughout the food product;
-Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit
-Food containers will be kept covered to retain heat and prevent environmental contaminants from entering the food;
-Measure and record the temperatures of each food product and milk at all meals. Record temperature on temperature log.
-When holding hot foods for service, food temperatures should be measured when placing it on the steam table
-If food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food.
-Potentially hazardous food that is cooked and cooled must be reheated so that all parts of the food reach and internal temperature of 165 degrees F for at least 15 seconds before holding for hot service.
-No food will be served that does not meet the food code standard temperatures.
-Food will not be cooked or reheated using the steam table because it does not bring food to the proper temperature within acceptable timeframes
-Place cold menu items such as ham salad or egg salad over an ice bath in a pan (preferably on a separate cart) and not beside a heated steam table.
-Food temperatures will be verified using a thermometer which is both clean, sanitized, and calibrated to ensure accuracy.
The facility did not provide food temperature logs.
Review of facility grievance reports showed on 1/6/23 resident said food is served to them cold due to meal cart sitting on hall for long periods of time before being passed and the cart door is being left open.
1. Review of Resident #10's record showed a Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), was not completed.
During an interview on 2/3/23 at 10:00 A.M., the resident said:
-The food was always cold;
-He/she was tired of asking to have food reheated, quit asking, and now eats his/her food cold;
-Last night the grilled cheese was burnt and cold;
-He/she seldom got hot water for tea;
-He/she occasionally got ice water, maybe once a day;
-The vegetables were always squishy and mushy.
2. Review of Resident #11's quarterly MDS, dated [DATE], showed the resident is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15.
During an interview on 2/3/23 at 10:00 A.M., the resident said:
-The food was always served cold;
-He/she was tired of asking for food to be warmed up.
During a follow up interview on 2/3/23 at 12:15 P.M., the resident said lunch was cold.
3. Review of Resident #12's quarterly MDS, dated [DATE], showed the resident is cognitively intact with a BIMS score of 14.
During an interview on 2/3/23 at 11:55 A.M., the resident said:
-He/she eats in his/her room;
-The food was cold upon arrival;
-He/she has notified staff that the food is cold; staff did not offer to reheat the food, staff shrugged their shoulders and left;
-The facility had one ice machine that worked and it died the other day;
-There are four ice machines in the building but only one works part of the time.
4. Review of Resident #15's annual MDS, dated [DATE], showed resident is cognitively intact with a BIMS score of 13.
During an interview and observation on 2/3/23 at 9:08 A.M., the resident said and showed:
-He/she has not had ice in the last three weeks;
-His/her cup had warm water and no ice;
-Staff do not serve ice water.
5. Review of Resident #16's quarterly MDS, dated [DATE], showed the resident has moderately impaired cognition with a BIMS score of 8.
During an interview on 2/3/23 at 9:35 A.M. the resident said his/her drinks are served at room temperature with no ice.
During an interview on 2/3/23 at 11:45 A.M., Certified Nurse Aide (CNA) A said:
-The kitchen and Village unit ice machines did not work;
-There has been no ice three to four days this week.
During an observation of the facility food cart on 2/3/23 at 12:20 P.M., showed the food cart was cool to touch and the door was not securely closed or latched.
During an observation of the food test tray passed after all residents on the [NAME] unit were served on 2/3/23 at 12:26 P.M. showed:
-Food was served on a normal plastic tray, the plate was on the tray with a plastic cover over top;
-Mixed fruit temperature was 63.9 degrees;
-Beef stroganoff temperature was 112.9 degrees;
-Green beans temperature was 99.4 degrees;
During an interview on 2/3/23 at 12:43 P.M., Head [NAME] A said:
-He/she has worked in the kitchen since June 2022;
-He/she was not aware of any food temperature complaints;
-Some residents have complained because the nursing staff leave food on the hall for over an hour while passing trays;
-Department heads have assisted kitchen with getting meals served on time as needed;
-Hall carts were not hot boxes and did not plug in;
-They do not have enough ice to give the residents.
During an interview on 2/3/23 at 3:24 P.M., CNA B said:
-He/she was not aware of any cold food complaints;
-He/she would warm up the food if needed;
-The facility's main ice machine was broken; there was only one machine on Village but it was not producing much ice;
-He/she passed water at the beginning of his/her shift and after dinner.
During an interview on 2/3/23 at 3:30 P.M., CNA C said:
-Resident #10 has complained of cold food;
-He/she would warm up the food if needed;
-He/she had taken cold food back to the kitchen for Resident #10.
During an interview on 2/3/23 at 3:39 P.M., Hospitality Aide said:
-He/she was not aware of any cold food complaints;
-Ice was available on the other end of building.
During an interview on 2/3/23 at 3:54 P.M. the Director of Nursing (DON) said:
-He/she expected staff to reheat food that was cold or send it back to the kitchen;
-He/she was not aware of any food temperature complaints.
During an interview on 2/3/23 at 4:00 P.M. Head [NAME] A said:
-Food temperatures were taken during meal preparation and on the steam table at service time;
-No previous temperature logs were available;
-Meat should be above 165 degrees and cold foods below 40 degrees.
During an interview on 2/3/23 at 4:44 P.M., Administrator said:
-Hot food should be served hot and cold food should be served cold;
-He/she expected staff to warm up cold food in the microwave or get a replacement tray.
MO213192
Dec 2022
2 deficiencies
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 F0558
(Tag F0558)
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 adhere to resident preferences when the facility staf...
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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 adhere to resident preferences when the facility staff did not provide two showers per week for four out of four sampled resident's (Resident's #1, #2, #3, #4) The facility failed to keep the sampled residents hair clean and bodies without odor. The facility census was 89.
Review of the Activities of Daily Living (ADL) policy dated March 2018, showed:
- Care and services will be provided to residents who are unable to carry out their own ADL's independently in accordance to the residents plan of care, including bathing and grooming.
Review of the resident rights policy dated December 2016 showed:
- The resident had the right to a dignified existence.
- The right to self-determination.
1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment performed by the facility staff) dated 8/30/22 showed:
- Diagnoses included: Muscle weakness, skin irritations, and pressure wound to his/her very low back.
- He/she had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment.
- He/she required the assistance on two staff when he/she repositioned in bed, was transferred, use to toilet, and get dressed.
- He/she was dependent on one staff when he she was bathed.
Review of the Activities of Daily Living (ADL) care plan dated 8/31/22 showed:
- He/she required the assistance of one staff when he/she took a shower.
- He/she was to be showered two times per week.
Hospital Registered Nurse (HRN) reported on 12/1/22 at 8:58 A.M.
- The resident arrived to the hospital with dirty matted hair and dirty body.
- The resident required a full bath because he/she was dirty
- When the resident's hair was combed, dirt and skin came off his/her head.
During an interview on 12/1/22 at 12:33 P.M. Resident #3 said:
- He/she was Resident #1's roommate.
- Resident #1's hair looked gross, it was matted and he/she had terrible dandruff that left chunks of white, dead skin on his/her mattress.
- Resident #1 did not get out of bed until he/she left to go to the hospital.
- He/she saw the facility staff give the resident a bed bath one time.
During an interview on 12/2/22 at 8:00 A.M. Certified Nurse's Aide (CNA) A said:
- He/she provided Resident #1 a bed bath one time a month ago.
- When he/she combed the resident's hair after he/she washed it, he/she combed out a bunch of dead skin off of the resident's head.
- The resident refused showers often during the past month.
- The staff were supposed to give the resident two bed baths per week.
2. Review of Resident #2's quarterly MDS dated [DATE] showed:
- Diagnoses included: Muscle weakness, need for assistance with personal cares, and unsteadiness on his/her feet.
- BIMS score of 15, indicating no cognitive deficit.
- He/she required the assistance of one staff to get dressed, use the toilet and bathe.
Review of the ADL care plan dated 9/16/22 showed:
- The resident required assistance of one staff with ADL's.
During an interview and observation on 12/1/22 at 12:15 P.M. the resident said:
- He/she wanted at least two showers per week, but was getting one shower per week.
- He/she felt dirty when he/she did not get showers two times per week.
- The resident had a musty body odor and his/her hair appeared dirty and greasy.
3. Review of Resident #3's quarterly MDS dated [DATE] showed:
- Diagnoses included: Arthritis of the right hip, pain of the right hip, and muscle weakness.
- BIMS score of 15, indicating no cognitive deficit.
- He/she required the assistance of one staff to transfer, get dressed, provide hygiene and to bathe.
Review of the resident's ADL care plan showed:
- He/she required supervision when bathing.
- The staff were to provide a bed bath when a shower was not tolerated by the resident two times per week and as needed.
During an interview and observation on 12/1/22 at 12:33 P.M. the resident said:
- He/she preferred to have a shower two times per week.
- He/she got a shower one time per week.
- He/she felt dirty when he/she did not get a shower two times per week.
- He/she had a musty body odor and his her hair appeared dirty and greasy.
4. Review of Resident #4's annual MDS dated [DATE] showed:
- Diagnoses included: Morbid Obesity and erythema intertrigo,(skin inflammation of the skin folds that can cause infection and tenderness).
- BIMS score of 15, indicating no cognitive deficit.
- He/she required the assistance of two staff to get dressed, use the toilet and to bathe.
Review of the resident's ADL care plan dated 11/1/21 showed:
- He/she required total dependence on two staff to bathe two times weekly and as needed.
- The staff were to provide a bed bath two times weekly when the resident was not able to tolerate a shower.
During an interview and observation on 12/1/22 at 1:17 P.M. the resident said:
- He/she had not had a shower for over two weeks.
- He/she last had a bed bath on 11/15/22 during night shift to prepare for a doctor's appointment the next day.
- He/she preferred two to three showers per week.
- He/she felt stinky, itchy, and dirty because he/she had not been bathed in so long.
- The resident had a musty body odor, his/her hair was greasy and stuck together in clumps at his/her scalp and down the shaft of the hair.
During an interview on 12/2/22 at 12:10 P.M. Licensed Practical Nurse (LPN) A said:
- He/she expected the CNA's to give the residents two showers per week.
- The showers did not always get done because there was not enough staff to complete the task.
During an interview on 12/2/22 at 12:53 P.M. the Director of Nursing (DON) said:
- She expected the facility staff to provide the residents two showers per week.
- She expected the resident's to be clean and comfortable.
During an interview on 12/2/22 at 2:35 P.M. the Administrator said:
- He expected the resident's to receive two showers per week.
- He would expect the resident's to remain clean and comfortable
*MO210580
MO210560
MO210235
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to maintain non-resident use areas in good, safe, and sanitary conditions. This effected three of eight shower rooms in the facility. The facili...
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Based on observation and interview, the facility failed to maintain non-resident use areas in good, safe, and sanitary conditions. This effected three of eight shower rooms in the facility. The facility census was 89.
1. Observation on 12/2/22 beginning at 9:45 A.M. showed the following:
- In the [NAME] hall's shower room, there were three holes in the ceiling, approximately 24 inches () by 7 inches, 24 by 36 and 24 by 40;
- In the Maple shower room (A-1), there was a 24 by 40 hole in the ceiling exposing the attic. There was also a 24 by 30 area in the ceiling that was covered by oriented strand board (OSB, type of engineered wood similar to particle board);
- Both shower rooms had debris including insulation and pieces of drywall on the floor. The rooms were in a condition that rendered them unusable by residents.
- The shower room in the central hallway by [NAME] had a large amount of wheelchairs and lifts stored in it. The shower was missing the shower head, it only had the hose to the head attached.
During an interview on 12/2/22 at 11:00 A.M., Certified Nurse Aide (CNA) A said:
- The shower rooms had been down for two to three weeks;
- They had been giving showers to residents on [NAME] in the central shower room since this Monday and it had been missing the shower head since then.
During an interview on 12/2/22 beginning at 9:45 A.M., the Maintenance Director said:
- A water line froze and busted in attic above the [NAME] shower room a couple weeks ago on 11/20/22 and another line busted in the attic above the Maple shower room on 11/21/22. Due to the insulation being wet, he wanted to let it all dry out before reusing the insulation and repairing the ceiling;
- He was going to reuse the insulation to save money;
- The ceiling in [NAME] was still intact but he tore it out yesterday due to the amount of water damage and the ceiling was sagging and it thought it would be dangerous to keep it up;
- Maple's ceiling was torn out the Monday following the incident;
- He planned to have the repairs done next week;
- He thought there was a shower head in the central shower room yesterday.
During an interview on 12/2/22 at 10:30 A.M., Regional Maintenance Staff said:
- He did not find out about the holes in the ceiling until today. He had been called in about a water line break but he was not aware there were holes in the ceiling from the incident;
- He did not think two weeks to repair the ceiling was a bad timeframe to ensure everything dried out to avoid mold.
During an interview on 12/2/22 at 12:00 P.M., the Administrator said:
- He started working at the facility on Monday, 11/28/22;
- He knew that one shower room ceiling was bowing;
- His main concerns was making sure residents were getting their showers;
- He did not know the central shower room was missing the shower head.
MO210580
Dec 2021
52 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents received adequate assistance devices to prevent accidents. The facility to ensure staff identified a bariatr...
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Based on observation, interview, and record review, the facility failed to ensure residents received adequate assistance devices to prevent accidents. The facility to ensure staff identified a bariatric resident who was unable to safely be evacuated from the facility in the event of an emergency (Resident #71), when the facility did not have a mechanical lift rated to safely transfer the resident. The facility census was 104.
The Administrator was notified on 12/15/21 at 4:16 P.M. of an Immediate Jeopardy (IJ) which began on 9/22/21. The IJ was removed on 12/16/21 as confirmed by surveyor onsite verification.
A review of the facility policy of Care and Treatment of Bariatric Residents, dated 11/1/21, showed:
-Bariatric residents have special needs. This facility will provide the necessary care and treatment that allows the bariatric resident to remain safe and attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. This policy also includes safety precautions for the caregiver to prevent injuries that may compromise the facility's ability to provide quality care.
1. Facility staff will identify equipment needs of the bariatric resident during the pre-screening and admission process. Equipment will be available upon admission for providing for the immediate needs of the resident.
2. The comprehensive assessment process will be utilized for identifying additional equipment needs. A person-centered care plan will be developed, based on specific factors identified in assessments and physician orders, and in accordance with the resident's goals and preferences.
3. Considerations for equipment needs include, but are not limited to:
a. A bed in which the dimensions are appropriate for the resident's size and weight.
b. Wheelchairs and other mobility aids.
c. Resident lifts that can accommodate resident's size and weight.
d. Shower chairs or commodes.
e. Aids to facilitate safe bed mobility, such as ergonomic turn sheets and limb slings.
4. Facility staff will treat bariatric residents with dignity and respect.
5. Care will be provided with the number of staff needed to ensure safety of the resident and the staff. To promote dignity and respect, safety shall be the emphasis, not the resident's weight.
7. All employees are responsible for following established policies and procedures regarding the care and treatment of bariatric residents, and the appropriate use of mechanical devices for safe resident handling.
Review of the facility's undated Emergency Preparedness policy regarding bariatric patients showed:
-For the purpose of evacuation, a bariatric resident will be lowered from the bed, using a bedsheet, to the floor. The staff will then pull the bariatric resident to safety using the bedsheet.
1. Review of facility's weight summary showed Resident #71 weighed 4/1/21 439 pounds (lbs);
- 5/7/21 477 lbs;
- 6/7/21 489.6 lbs;
- 7/1/21 488 lbs;
- 8/10/21 494 lbs;
- 9/22/21 509.8 lbs.
Review of the resident's progress note, dated 9/22/21 at 3:43 P.M., showed: Restorative Aid (RA) A noted the resident had maxed weight limit for mechanical lift. Unable to safely weigh moving forward. Admin notified of issue.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandataed assessment tool, dated 10/27/21, showed:
-Cognitively intact;
-Extensive to total assistance with Activities of Daily Living (ADL), including dressing, bed mobility and bathing;
-Limited Range of Motion to both upper extremities and both lower extremities;
-No weight was recorded.
Review of the resident's care plan, dated 11/3/21, showed:
-Required assistance of 2 staff with bathing/showering twice weekly and as needed, using Hoyer lift.
-Required a mechanical lift Hoyer with 2 staff assistance for transfers. Uses wheelchair propels self.
-There were no problems or approaches addressing the resident's weight had exceeded the lift capacity and cannot be transferred from the bed.
Observation on 12/14/21 at 9:37 A.M., showed the resident lying in bed, wearing hospital gown. His/her lower legs and feet appeared swollen and red with visible dry, flaky skin.
During an interview on 12/14/21 at 9:37 A.M., the resident said:
-He/she had not left the bed since August, as there was not a lift in the facility that can handle the resident's weight.
-He/she would like to shower, but he/she cannot get out of bed.
-The facility had given him/her a wheelchair to use, but he/she can't use it because it was not big enough and hurt to use it.
-When asked how the facility would evacuate him/her during the event of an emergency, the resident said he/she wasn't sure and I'd guess I'd die.
During an interview on 12/15/21 at 11:18 P.M., Certified Nurse Assistant (CNA) B said:
-He/she was familiar with the resident.
-He/she was unsure how the staff would evacuate the resident in the event of an emergency. He/she would unlock the breaks of the bed and push the bed out, if it fit through the door.
-If the bed wouldn't fit through the door, he/she would use a Hoyer lift.
-He/she was unsure what weight the lift was rated to.
-CNA B reviewed the lift on the resident's unit. The sticker on the lift showed the lift was rated to 500 pounds.
-CNA B said that there may be a higher rated lift elsewhere in the building, but was not sure.
During an interview on 12/15/21 at 11:28 A.M., CNA D said:
-The mechanical lift on the unit he/she worked on was rated to 450 pounds.
-There may be a bigger bariatric lift somewhere in the building, but he/she was not sure.
-He/she had worked with the resident a few times.
-He/she was unsure if he/she had to evacuate the resident from the building how he/she would do so.
During an interview on 12/15/21 at 12:57 P.M., Licensed Practical Nurse (LPN) B said:
-If the resident needed to be evacuated from the facility, he/she would try to remove the bed from the room.
-If the bed would not fit through the door, he/she is unsure how he/she would evacuate the resident, as there is no lift in the building rated for the resident's weight to safely transfer the resident.
Observation of the resident on 12/15/21 at 2:10 P.M., showed:
-Emergency Medical Services (EMS) were called to transfer to the resident to the hospital.
-Six EMS responders were required to transfer the resident from bed to the ambulance stretcher.
Observation of the the resident's room on 12/15/21 at 3:12 P.M., showed:
-Bed frame width 48 inches;
-Door frame width with the door on the hinges is 41.5 inches;
-Door frame width without the door on the hinges is 43.5 inches.
During an interview on 12/15/21 at 3:45 P.M., the Former Administrator said:
-He/she was unaware there was not a lift in the facility that was not rated to safely transfer the resident.
-If the resident did need to be evacuated from the facility, staff would need to call 911.
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
This deficiency is uncorrected. For previous deficiencies, see the statement of deficiencies dated 10/27/21.
Based on observation, interview, and record review, the facility failed to prevent one resi...
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This deficiency is uncorrected. For previous deficiencies, see the statement of deficiencies dated 10/27/21.
Based on observation, interview, and record review, the facility failed to prevent one resident with a history of physically and sexually aggressive behaviors (Resident #81) from abusing multiple residents. The facility census was 89.
Review of the facility policy for Abuse, Neglect, and Exploitation included the following:
- It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
- Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.
- An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.
- Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.
- Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause.
- Providing complete and thorough documentation of the investigation.
- Taking all necessary actions as a result of the investigation, which may include, but are not limited to; analyzing the occurrences to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; defining how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstration of staff competency after training is implemented; identification of staff responsible for implementation of corrective actions; the expected date for implementation, and identification of staff responsible for monitoring the implementation of the plan.
1. Review of Resident #81's care plan for potential for a behavior problem related to agitation/delirium dated 12/31/21 showed:
-Focus: potential for a behavior problem related to agitation and delirium, wanders in his/her wheelchair;
-Goal: will have no aggressive behaviors through review;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; anticipate and meet the resident's needs; explain all procedures to the resident before starting; if reasonable, discuss the resident's behaviors. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.
Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 2/12/22 showed:
-Unable to answer questions, unaware of the date, time and person;
-No mood issues and no behaviors;
-Extensive assistance of two staff for Activities of Daily Living (ADL's);
-Five days of antipsychotic usage (a mediation used to control behaviors and mood);
-Diagnoses of dementia, aphasia (inability to speak), manic depression (Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions).
Review of the nurse's notes dated 1/26/22 at 12:52 P.M. showed:
-Resident in the dining room, slapped another resident in the face. Resident sent to local hospital.
Review of the nurse's notes dated 1/26/22 at 7:24 P.M. showed:
-Resident returned from local hospital with no new orders. Continue to monitor.
Review of the care plan for behaviors dated 12/31/21 showed no changes or additional approaches related to behavior after the 1/26/22 altercation.
Review of the nurse's notes dated 1/29/22 at 8:43 A.M. showed:
-At approximately 5:50 A.M., the resident was seen pushing another resident to the floor. This resident was removed from the dining room and sent to a local hospital.
Review of the nurse's notes dated 1/29/22 at 11:30 P.M. showed:
-The resident returned from the local hospital at 12:30 P.M. with no new orders
Review of the care plan for behaviors dated 12/31/21 showed no changes or additional approaches related to behavior after the 1/29/22 incident.
Review of the nurse's notes dated 1/31/22 at 5:27 P.M. showed:
-The resident required re-direction following inappropriate contact with staff. He/she made contact with the buttocks of a female staff member. The resident was educated.
Review of the nurse's notes dated 2/1/22 at 7:03 A.M. showed:
-The resident has been seeking out female peers to sexually molest. Nurse has had to keep him/her in the line of sight at all times since 5:00 A.M. The resident had at least four near misses with four different residents. Staff was able to intervene quickly. Interim administrator notified and he/she came to the unit to address the resident's behaviors.
Review of the nurse's note dated 2/1/22 at 8:59 A.M. showed:
-The resident was found lying in bed with a female resident with his/her pants down. The resident was trying to pull the female resident's pants down. The resident was assisted back to his/her room. A female resident entered the resident's room, the resident became aggressive toward him/her as well. The resident sent to the local hospital for evaluation.
Review of the nurses' note dated 2/1/22 at 12:54 P.M. showed:
-Local hospital called to report the resident will be admitted to a psychiatric hospital.
Review of the nurse notes dated 2/11/22 at 2:43 P.M. showed:
-The resident was readmitted to the facility from psychiatric hospital.
Review of the care plan for behaviors dated 12/31/21 showed no new approaches to address the sexually inappropriate behaviors toward residents and staff, or any new interventions from the recent psychiatric hospital admission.
Review of the nurses notes dated 2/13/22 at 1:22 P.M. showed:
-The resident was showing aggressive and inappropriate behavior toward nurses, Certified Nurse Aides (CNA's) and other residents and would not stop when asked to. Staff had to physically remove the resident's hands from touching inappropriately. The resident also slapped another resident in the face twice. The resident was sent to a local hospital for evaluation.
Review of the care plan for behaviors dated 12/31/21 showed no new interventions to address the inappropriate behaviors of 2/13/22, the physical aggression towards another resident, or the recent hospitalization.
Review of the social services note dated 2/24/22 at 8:57 A.M. showed:
-Social Services communicated with the resident's guardian. The resident's guardian has expressed a need to have the resident moved to a behavior facility. Referrals have been sent.
Review of the nurse's note dated 2/25/22 at 7:58 P.M. showed:
-The resident has been doing sexual things again. He/she tried to grab another's back side this evening. He/she has had several behaviors taking briefs, trying to get in a cart, exit seeking for hours. He/she then started spitting on the floor in the hallway. He/she was then directed to his/her room by staff and told to stay in there.
Review of the nurse's dated 2/26/22 and 2/27/22 showed:
-9:40 A.M. - Upon arrival this nurse was informed the resident had been having behaviors. As directed by the Assistant Director of Nursing (ADON) this nurse placed a call to the guardian. With an approval to send the resident to the hospital. Resident left the facility at 9:34 P.M. for evaluation;
-10:28 A.M. - nurse at the hospital called for report as to why the resident was at the hospital;
-12:13 A.M. - the resident returned to the facility.
Review of the nurse's notes dated 2/28/22 at 2:46 P.M. showed:
-The resident sent to a hospital for evaluation related to sexual aggression, grabbing buttocks and private areas of other residents and staff. The resident also pulled the fire alarm and was exit seeking all shift.
Review of the nurse's notes dated 3/1/22 showed:
- 12:52 A.M. Spoke with the hospital's professional team with recommendations for the resident to return to the facility and see the facility's psychiatrist for a mediation adjustment;
-3:24 A.M. the resident is transferred back to the facility.
-9:23 A.M. the resident continues to grab at staff's buttocks and is going in other resident's rooms;
-6:27 P.M. the resident was into everything this evening. Attempted to get into nursing station, in stuff on the cart. Kept going to the doors. Standing up from the wheelchair and having to be told to sit down as he/she was unstable on his/her feet.
Review of the care plan for behaviors dated 12/31/21 showed no new interventions for the sexually aggressive behaviors, nor of the resident being sent to a psychiatric hospital.
Review of the nurse's notes dated 3/5/22 showed:
- 2:18 P.M. The resident came into the dining room and propelled next to another resident. He/she said something to this resident. The resident said something to him/her, then he/she slapped this resident with an open hand on the cheek two times. This writer immediately separated the two residents and took this resident to his/her room because he/she stated he/she was tired. The resident was sent to a local hospital for evaluation.
-11:00 P.M. the resident returned from the hospital with no new orders.
Review of the social services note dated 3/7/22 at 9:07 A.M. showed:
-The IDT team met to discuss the resident's recent behaviors. Resident can display inappropriate touch of other people. He/she has been sent out for psychiatric hospitalization on 1/21/22, 1/29/22, 2/1/22, 2/27/22 and 2/28/22. Resident currently takes Risperdal (used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, irritability associated with autistic disorder) for bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). Quetiapine (Seroquel, an antipsychotic medicine that is used to treat schizophrenia (a serious mental disorder in which people interpret reality abnormally.) for unspecified dementia, bipolar disorder and mood.
During the observation period of 3/21/22 through 3/23/22 showed the resident was on one on one observation by one staff member.
Review of the behavior care plan dated 12/31/21 showed no changes or addition of interventions for the sexually aggressive behaviors, the admissions to the psychiatric hospitals, the medication used, or the one on one interventions used.
Review of the nurse's notes dated 3/8/22 through 3/19/22 showed documentation of the resident's continued sexually inappropriate behaviors. Review of the care plan showed no documentation for any interventions in place for staff to utilize for the sexually inappropriate behaviors.
During an interview on 3/23/22 at 2:00 P.M. the Corporate Nurse and Director of Operations said;
-They were aware of the resident's physically aggressive behaviors and were attempting to find appropriate placement for the resident. They have sent out referrals to several facilities, but at this point no one will take the resident.
During an interview on 3/24/22 at 2:00 P.M. the interim Director of Nursing said:
-Staff should receive training for residents with behaviors through in-servicing from the management staff or training from outside educators on how to address the resident's behaviors.
-Staff should identify the residents behavior, put interventions in place to address the behavior, update the care plan then educate the staff on the interventions.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or m...
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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 the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for two of 24 sampled residents (Resident #84 and #88). Staff failed follow their policy for skin assessments and wound care treatment for Resident #84 when the resident was found to have a wound on a toe that required hospitalization and failed to assess the residents skin after a hospitalization which resulted in a delay in treatment for another wound. The facility failed to monitor Resident #88's condition when the resident had an altered state of consciousness and failed to use appropriate standards of practice when staff administered narcotics more than ordered by the physician. The facility census was 104.
Review of the facility policy for Wound Treatment Management dated 11/1/21 showed:
-Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;
-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change;
-In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse;
-Treatment decisions will be based on:
a. the etiology of the wound: pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage, surgical, incidental or atypical;
b. the characteristics of the wounds;
c. the location of the wound;
d. goals and preferences of the resident/representation;
-The facility will follow specific physician orders for providing wound care;
-Treatments will be documented on the Treatment Administration Record (TAR);
-The effectiveness of treatments will be monitored through ongoing assessments of the wound.
The facility did not provide a policy for skin assessments.
1. Review of Resident #84's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff), dated 11/5/21 showed:
-Unable to answer questions;
-Extensive assistance of one staff for dressing, transfer, limited assistance of one staff member for walking, locomotion and dependent upon one staff member for personal hygiene;
-Incontinent of bowel and bladder;
-Diagnoses of hypertension (HTN, high blood pressure), diabetes (DM), stroke (Cerebral Vascular Accident (CVA), aphasia (inability to speak due to the CVA), and psychotic disorder (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions.);
-At risk for pressure ulcers and no wounds marked.
Review of the care plan for Diabetes Mellitus (DM) dated 5/17/21 showed in part:
-Focus: the resident has DM;
-Goal: the resident will have no complications related to DM through the review date with a revision date of 8/26/21;
-Interventions/task: Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness;
-Monitor/document/report as needed (PRN) any signs and/or symptoms of infection to any open area: redness, pain, heat, swelling or pus formation.
Review of the weekly skin check dated 11/10/21 and 11/23/21 showed no wounds or open areas.
Review of the medical record showed no weekly skin check for 11/17/21.
Review of the bath sheets completed by staff dated 10/29/21 showed no wounds notes, 11/18/21 showed the resident refused.
The facility was unable to provide any other bath sheets to show the resident received a bath or that nursing staff assessed the resident's skin.
Review of the nurses notes dated 11/28/21 signed by Licensed Practical Nurse (LPN) B at 4:49 P.M. showed:
-The resident's second toe on the right foot looks black and moist;
-The right foot looks slightly swollen and red but not warm to the touch;
-A black spot on the left toe was noted;
-The resident appeared to have pain when providing care to the area. PRN Tylenol administered with effectiveness;
-Notes faxed to the resident's physician. The Director of Nursing (DON) was aware. The family was notified.
Review of the nurses notes dated 11/29/21 at 3:32 P.M., signed by LPN B, showed:
-Physician was to order Keflex (medication is used to treat a wide variety of bacterial infections) 500 milligrams (mg) four times a day (QID) for wound on second toe on the right foot.
Review of the undated care plan for skin showed in part:
-11/29/21: Focus: the right foot, second toe, is black/moist; there is a black spot on the toe on the left foot;
-Goal: did not specify a goal for the areas to the feet;
-Interventions/task: 11/29/21: the toe is to be cleaned with wound cleanser (WC) and Tylenol to be given for signs/symptoms of pain while treating the area. All parties were notified.
Review of the physician's progress note dated 11/30/21 at 11:42 A.M. signed by Physician A showed:
-Notified by nursing the resident had digital ulcers of the left foot. Examination of the right foot demonstrates the second toe has circumstantial dry gangrene (This type of gangrene involves dry and shriveled skin that looks brown to purplish blue or black. Dry gangrene may develop slowly. It occurs most commonly in people who have diabetes or blood vessel disease, such as atherosclerosis; is a dangerous and potentially fatal condition that happens when the blood flow to a large area of tissue is cut off. This causes the tissue to break down and die. Gangrene often turns the affected skin a greenish-black color.). Diminished capillary refill and cool, no odor, no discharge, no drainage. The duration is unknown, first documentation is 11/28/21. The resident is currently on Plavix ( used to prevent heart attacks and strokes in persons with heart disease (recent heart attack), a recent stroke, or blood circulation disease, and Atorvastatin (used to lower cholesterol ) and weekly skin assessments.
Review of the nurses notes dated 11/30/21 at 12:32 P.M. showed:
-The physician came in to see the resident's toe on his/her right foot. The physician asked for the resident to be sent to the hospital for treatment of the right foot, second toe, being black. Right foot is edematous (swelling) with mild redness and warm.
Review of the nurses notes dated 11/30/21 at 10:04 P.M. showed:
-Update on the resident's status at local hospital, the resident was admitted with diagnosis of gangrene.
Review of the hospital admission paperwork dated 11/30/21 showed:
-Resident had a right foot wound. He/she was at a nursing home and they noticed his/her right second toe was black, two days ago;
-Right, second toe appears ischemic (an inadequate blood supply to an organ or part of the body) in nature. Unable to assess pedal pulses (pulses found in the top of the foot);
-X-ray results showed an infection in the second toe on the right foot;
-Diagnosis of gangrene to the second toe on the right foot;
-Resident is not a candidate for surgical interventions at this time. Recommend conservative measures.
Review of the nurses note, dated 12/7/21 at 3:48 P.M., showed:
-The resident was readmitted to the facility from a local hospital. Spoke with nurse from the local hospital who said the resident had a CT (computed tomography scan - A procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body.) of the second toe of the left foot and no osteomyelitis (inflammation of bone or bone marrow, usually due to infection.) was found. The resident was not a candidate for surgical amputation. New orders to cleanse the wound, apply betadine, and then wrap the toe.
Review of the the weekly skin check dated 12/8/21 showed:
-Scabs to the left knee. Intact, dry dressing on the toes of the right foot. A scab from a blood blister on the fifth toe of the left foot.
During an observation on 12/9/21 at 11:26 A.M. showed:
-The resident lying in bed with his/her right foot wrapped with a Kerlix dressing.
-LPN C removed the dressing to the foot;
-The second toe to the right foot was black in color;
-The resident moaned when the nurse removed the dressing and pulled his/her foot back.
During an interview on 12/9/21 at 11:40 A.M. LPN C said:
-He/she had only worked with the resident a couple of times, he/she does not normally work the hall where the resident resides;
-He/she had not seen the resident's toe prior to this day.
During an interview on 12/9/21 at 1:35 P.M., Certified Nurse Aide (CNA) A said:
-He/she has worked the hall the resident lives on for about a month;
-He/she had noticed the second toe on the right foot was black couple of weeks ago;
-He/she reported this to a nurse, but he/she does not remember which nurse;
-There is no place for CNA's to document when a resident has a skin condition.
During an interview on 12/9/21 at 2:35 P.M., LPN B said:
-He/she frequently works the hall the resident lives on;
-He/she was the nurse who reported the black area on the second toe on the right foot to the physician on 11/28/21;
-11/28/21 was the first time that the area was reported to him/her.
During an interview on 12/10/21 at 10:18 A.M. the former Director of Nursing (DON) said:
-He/she was unaware of the black area on the second toe on the right foot, until 11/28/21.
During an interview on 12/10/21 at 12:42 P.M. LPN D said:
-He/she had been the wound nurse several months ago, but resigned as he/she had not received any training and was being pulled to the floor to work as a nurse on the floor;
-There is currently no wound nurse in the facility;
-He/she was unaware of any skin issue for the resident, until the nurse found the area to the second toe on the right foot and the resident went to the hospital.
-He/she is not aware of any other skin issues for the resident.
Observation on 12/11/21 at 8:30 A.M. showed the resident slumped over in a dining room chair. A staff was attempting to arouse the resident. LPN D called for assistance and instructed the staff to call 911. Emergency medical services (EMS) arrived a few minutes later and the resident was transported to the hospital.
Review of the hospital records dated 12/12/21 showed:
-Resident has a past medical history of dementia, hypertension, diabetes and necrotic right toe. History is limited due to the residents inability to communicate. Resident was minimally responsive with the nursing staff and he/she did not eat his/her breakfast which is unusual. He/she had a fever of 100 degrees. EMS was subsequently called. The resident was recently admitted to another hospital for a necrotic second digit of the right foot. He/she was deemed not a surgical candidate and was treated with IV (intravenous, an apparatus used to administer a fluid (as of medication, blood, or nutrients) intravenously) antibiotics and was discharged upon completion.
-The resident appears to have a blister/wound to the left foot. The left fifth toe/lateral aspect (outer portion of the foot) shows skin loss with erythema (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries). Tender to touch.
-Hospital course: the resident was admitted for fever and altered mental status most likely due to cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin. If untreated, it can spread and cause serious health problems.) of the left foot.
-Resident has encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition (such as viral infection or toxins in the blood) most likely due to underlying infection versus worsening dementia
Review of the medical record showed no documentation of the resident returning to the facility on [DATE].
Observation and record review on 12/13/21 at 8:43 A.M. showed:
-A small dressing on the fifth toe on the left foot. There was a black area on the toe. The dressing was removed showing a small open area on the outer aspect of the fifth toe. The area was open with a scant amount of clear drainage. There was no documentation in the nurses notes of the open area and no documentation of the resident responsible party being not notified of the area.
During an interview on 12/13/21 at 1:48 P.M. Physician A said:
-He/she was first notified of the blackened toe on 11/27/21, he/she seen the resident on 11/30/21. The resident has severe Peripheral Vascular Disease (PVD), and he/she diagnosed the toe with dry gangrene and gave orders to be sent to the hospital. Resident returned to the facility. The resident is not a candidate for surgery.
Review of the weekly skin check dated 12/14/21 showed an existing right foot/toe wound scattered bruising to both lower extremities, both upper extremities and back. No new wounds identified.
During an interview on 12/14/21 at 3:22 P.M. LPN E said:
-He/she had worked on the Village recently and had taken care of the resident;
-He/she was not aware of any problems with his/her skin or having any wounds;
-If a resident is gone for over 24 hours then the resident should be treated like a new admission. A skin assessment should be completed and documented in the nurses notes. If less than 24 hours, document that they went out and document that they came back.
During an interview on 12/14/21 at 3:08 P.M. CNA C said:
-He/she has been an aide for six years and works on Village;
-The resident will say NO, regardless of what you say or ask, but can talk with him/her and he/she will let you take care of him/her;
-He/she was aware of the wound to the second toe on the right foot;
-A couple of weeks ago, his/her sock was off his/her foot and he/she seen his/her toe. The toe was little bit cracked in the middle. It looked like old old skin. A week before that he/she tried to put his/her shoe on and he/she complained of pain, he/she just thought his shoes were too small;
-Evening shift does not take the resident's socks off, as they may get up and need socks to keep them from falling;
-He/she has not seen his/her feet recently.
During an interview on 12/14/21 at 2:53 P.M., LPN C said:
-He/she is taking care of the resident today;
-When a resident comes back from the hospital, the hospital usually sends a packet of paperwork about their hospital stay and orders;
-The Unit Manager usually has the paperwork;
-He/she does not have any paperwork from hospital;
-He/she is unaware of any new wounds.
-He/she does not have any new treatment orders other than the treatment to the second toe to the right foot.
Review of the weekly skin check dated 12/15/21 showed: appears to have old scratches and abrasions on the left knee, no signs or symptoms of infection observed. Current dressing to foot in place. No new wounds identified.
During an interview on 12/15/21 at 1:29 P.M. LPN D said:
-The resident returned to the facility from the hospital on [DATE] with cellulitis of the left foot, he/she did not have any new orders. The resident was suppose to go to hospice. Hospice said he/she does not qualify for hospice services;
-On 12/9/21 a nurse aide came and showed him/her an abrasion like area to the fifth toe on the left foot. The resident has bruises from IV's that were given at the hospital;
-He/she documented the information in Risk management tab in the electronic medical record. The Director of Nursing (DON) and the Administrator will look at the information that is documented in the Risk management tab. He/she cannot find the information in the Risk Management tab or in the nurses notes;
-He/she notified the physician via a fax communication. The fax communication should be kept on a clip board until the physician answers the fax, then the fax is sent to medical records to be filed. The Fax machine on the Village does not work, so the nurses have to go to other halls to fax paperwork. He/she cannot find the fax that he/she sent to the doctor. He/she has not received any orders for the treatment to the area, he/she has just putting a dry dressing on the area;
-He/she was not aware of the black area to the toe.
Review of the medical record dated 12/12/21 through 12/22/21 showed:
- No treatment for wound on the left foot.
During an interview on 12/15/21 at 10:00 A.M. Family Member A said:
-He/she was made aware of the wound to the toe on the right foot a couple of weeks ago, the nurses then called the next day and told him/her that the resident was going to the hospital due to the wound;
-He/she felt the decline in the wound happened quick.
-He/she was not aware of any wound to the left foot until the hospital told him/her about the wound on the left foot when the resident was at the hospital on [DATE].
During an interview on 12/15/21 at 1:59 P.M. the former Administrator said:
-Nurses will document in the Risk Management area in Point Click Care (PCC), the electronic medical record. The Interdisciplinary Team (IDT) team will review the information to see if they need to add any information. The administration will then review the information and then lock it the entry in PCC. She can see an entry in the Risk Management section for the resident dated 12/10/21 of a new skin issue. An aide alerted the nurse that the resident had a new skin issue to 5th digit on the left foot, the wound was cleansed and dressed;
-She would expect that a wound report would be competed , and reported to wound care plus (the outside wound care provider), and the Director of Nursing (DON) should have done the wound report. The DON would have been in charge of doing the wound assessment or assigning it out to be done;
-The DON resigned on 12/13/21.
During an interview on 12/20/21 at 10:00 A.M. LPN D said:
-He/she does not have a treatment order for the wound on the left foot;
-He/she has been putting on alginate dressing (Alginate dressings can absorb wound fluid in the dry form and form gels that can provide a dry wound with a physiologically moist environment and minimize bacterial infections, thereby promoting rapid re-epithelialization and granulation tissue formation) and border gauze;
-He/she has asked for a wound care policy, but has not been provided one yet;
-He/she does not know if the facility has a policy for wounds.
During an interview on 12/20/21 at 10:00 A. M. LPN E said:
-No wound assessments have been done on the resident's wounds;
-He/she has asked for a wound care policy, but has not been provided one yet;
-He/she does not know if the facility has a policy for wounds;
-The facility does not have a wound nurse.
Review of the nurses notes dated 12/20/2021 at 11:51 A.M. showed:
-The Nurse Practitioner was in this shift and wrote new orders for wound cultures to both wounds on feet and new order for antibiotic. Family notified.
Review of the resident's medical record dated 12/13/21 through 12/23/21 no documentation of wound assessments, no documentation of any open areas or wounds to the left foot.
During an interview 12/22/21 4:22 P.M. the Interim Director of Nursing and Corporate Nurse B said:
-The charge nurses complete the weekly skin check;
-The wound assessment should consist of the actual wound measurements;
-Weekly skin check is triggered in PCC (point click care, the facility electronic medical record) schedule;
-If there is abnormal skin or wound, the nurses should notify the physician;
-Residents who have existing wound only new wounds document on the skin assessment that the resident has a wound, if a new wound is found upon the skin assessment, then the nurse would document the wound and measurements;
-The DON or nurse manager or charge nurse is responsible for weekly wound documentation. If the facility has a wound nurse, then the wound nurse would be responsible for the weekly documentation. The facility does not have a wound nurse at this time;
-She is not aware of any new wound for the resident;
- When a new area is found the nurses should notify the DON and document in Risk Management tab in PCC;
-The Risk Management note goes to the DON, the DON is to ensure that the physician is notified, and orders are received;
She expects the nurses should assess the residents and document when a resident returns from the hospital.
During an interview on 12/22/21 at 5:00 P.M. Physician A said:
-He/she would expect the facility to follow their policy and procedure for wound care and pressure ulcer care and treatment. He/she is aware that the facility does have a policy.
2. Review of the facility's pain management policy, dated 11/1/21, showed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences.
- Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics:
a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain.
b. Consider evidence-based practice tools to assist in the assessment of the resident's pain.
c. Consider administering medication around the clock instead of PRN (pro re nata/on demand) or combining longer acting medications with PRN medications for breakthrough pain.
d. Utilize the most effective and least invasive route for analgesic administration (e.g. oral, rectal, topical, injection, infusion pump and/or transdermal)
e. Use lower doses of medication initially and titrate slowly upward until comfort is achieved.
f. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects.
g. Review clinical conditions which may require several analgesics and/or adjuvant medications; documentation will clarify the rationale for a treatment regimen and acknowledge associated risks.
h. Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturers ' guidelines to optimize their effectiveness and minimize their adverse consequences.
i. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen.
j. Referral to a pain management clinic for other interventions that need to be administered under the close supervision of pain management specialists will be considered for residents with more advanced, complex or poorly controlled pain.
- The policy directed staff to do the following for monitoring, reassessment and care plan revisions:
a. Facility staff will reassess resident's pain management for effectiveness and/or adverse consequences (e.g., constipation, sedation, anorexia, change in mental status, delirium, respiratory depression, pruritus, nausea, vomiting, addiction and falling or drowsiness) at established intervals.
b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated.
c. If pain has resolved or there is no longer an indication for pain medication, the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics.
Review of Resident #88's admission MDS, dated [DATE] showed:
- A BIMS of 15 which indicated no cognitive impairment;
- Feeling down, depressed or hopeless at least one day during the assessment period; no behaviors noted;
- Independent with all ADLs with the exception of needing limited staff assistance for dressing and supervision with toilet use; did not walk in corridor or room;
- Diagnoses included: stroke; psychoactive substance abuse, alcohol related disorder, palliative care, anxiety, depression, high blood pressure, congestive heart failure, Stage 3 chronic kidney disease, right side paralysis;
- Has been on a scheduled pain medication in the last five days, has not taken any PRN (as needed) pain medications; not experiencing any pain at the time of the assessment;
- Has a chronic disease or condition that may result in a life expectancy of less than six months;
- Received antianxiety medications four of the past seven days; antidepressants seven of the past seven days; received opioid (highly addictive narcotic pain medications) medications seven of the past seven days;
- Hospice care.
Review of the resident's quarterly MDS, dated [DATE], showed:
- Received PRN pain medications; did not receive any non-medication interventions for pain;
- Frequently experienced pain; pain has made it hard to sleep at night; pain has limited day-to-day activities; rated his/her pain at a 10;
- Received antipsychotic medications two of the last seven days; antianxiety medications seven of the last seven days; antidepressants seven of the last seven days; opioid medications seven of the last seven days;
- Hospice care.
Review of the resident's entry MDS showed he/she readmitted from the hospital on [DATE].
Review of the resident's undated care plan showed:
- On a sedative/hypnotic medication related to insomnia (Melatonin). Interventions included:
o
Administer sedative/hypnotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift.
o
Evaluate other factors potentially causing insomnia, for example: environment (excessive heat, cold, or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy.
o
Monitor/Document/Report PRN for following adverse effects of sedative/hypnotic therapy: day time drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness.
o
Report pertinent lab results to physician.
- The resident uses anti-anxiety medications related to anxiety disorder. interventions included:
o
Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift.
o
Monitor the resident for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs.
o
Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucination
o
Monitor/record occurrence of for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol.
o
Psychiatry consults as needed
- The resident uses antidepressant medication related to depression. Interventions included:
o
Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift
o
Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts,
o
withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea and vomiting, dry mouth, dry eyes
o
Psychiatry consults as needed;
- The resident has chronic pain related to stroke with right side paralysis; 11/6/2021 Screaming about his nerve pain to his feet; Refuses pain patch at times. Interventions included:
o
11/6/2021: screaming that his/her nerve pain in his/her feet are worse; physician/Hospice called and ordered dosage changes to his/her Neurontin (used to treat nerve pain)/Baclofen (treat pain and certain types of spasticity). Few HRS later was screaming again about the pain. Hospice notified and came out to exam him/her; received orders medication changes; see medication administration record (MAR).
o
Administer analgesia as per orders.
o
Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.
o
Evaluate the effectiveness of pain interventions Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.
o
Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function.
o
Identify, record and treat The resident's existing conditions which may increase pain and or discomfort: paresthesia related to stroke
o
Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea and vomiting; dizziness and falls. Report occurrences to the physician.
o
Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss.
o
Monitor/record/report to Nurse if resident complaints of pain or requests for pain treatment.
o
Notify Hospice and place on Dentist list
o
Notify physician if interventions are unsucc
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
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 follow their policy for Pressure Injury (PI) Preventi...
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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 their policy for Pressure Injury (PI) Prevention and Management and Wound Treatment Management for two sampled residents (Resident #254 and #52), when the facility failed to assess the residents Pressure Ulcer's (PU) and failed to follow physician's order for wound treatment for one resident (Resident #52). The facility census was 104.
Review of the facility policy for Pressure Injury Prevention and Management dated 11/1/21 showed:
-This facility is committed to the prevention of avoidable pressure injuries and promotion of healing of existing pressure injuries;
-Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate;
-The facility shall establish and utilize a systematic approach for the PI prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate;
-Assessment of PI risk:
-Licensed nurses will conduct a pressure injury risk assessment, using (fill in blank for designated tool), on all residents upon admission/readmission, weekly times four weeks, then monthly or whenever the resident's condition changes significantly;
-The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: impaired/decreased mobility and decreased functional ability; co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus; exposure of skin to urinary and fecal incontinence; under nutrition, malnutrition, and hydration deficits; and the presence of a previously healed PI;
-Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly and after any newly identified PI. Findings will be documented in the medical record;
-Assessments of PI will be performed by a licensed nurse, and documented on the (fill in the black for designated form). The staging of PI will be clearly identified to ensure correct coding on the Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff;
-Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task;
-Training in the completion of the PI risk assessment, full body skin assessment,a and PI assessment will be provided as needed.
Review of the facility policy for Wound Treatment management dated 11/1/21 showed:
-Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders;
-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change;
-In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse;
-Treatment decisions will be based on: a. the etiology of the wound: pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage, surgical, incidental or atypical; b. the characteristics of the wounds; c. the location of the wound; d. goals and preferences of the resident/representation;
-The facility will follow specific physician orders for providing wound care;
-Treatments will be documented on the Treatment Administration Record (TAR);
-The effectiveness of treatments will be monitored through ongoing assessments of the wound.
1. Review of Resident #254's admission skilled nurses notes dated 4/20/21 showed:
-admission: skin: mottled (lack of blood flow throughout the body);
-Pressure ulcers: feet are discolored with a wound to the left heel. Bilateral feet are scaly and cracked.
Review of the wound assessment dated [DATE] showed:
-Left buttock, Stage 1 (Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it then remove your finger). Area is pink and is resolved.
Review of the care plan for PU dated 4/21/21 showed:
-Focus: Resident has a PU to the left heel and a left buttock wound;
-Goal: PU will show signs of healing and remain free from infection;
-Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness; administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing with every treatment, measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed and healing process. Report improvements and declines to the physician; educate his/her family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent reposition; follow facility policies/protocols for the prevention/treatment of skin breakdown; low air loss mattress; monitor nutritional status; monitor and document and repot any changes in skin status, appearance, color, wound healing, signs and symptoms of infections, wound size, assistance to turn/reposition at least every two hours, more often as needed or requested; weekly treatment documentation to include measurements of each area of skin breakdown.
Review of the nurses notes dated 4/21/21 showed the resident was admitted to the facility Physician orders dated 4/21/21 showed an order to cleanse the left buttock with wound cleanser, pat dry and skin protectant to periwound (area around the wound), apply Silicon adhesive pad, change every day and as needed, in the morning to the PU of the sacral region, which is unstageable.
Review of the admission MDS dated [DATE] showed:
-Unable to answer questions;
-Dependent upon staff for Activities of Daily Living (ADL's);
-Incontinent of bowel and bladder;
-Diagnoses of coronary artery disease (CAD), Alzheimer's disease, Parkinson's disease (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination.) and depression;
-At risk for development of pressure ulcers (PU);
-One Stage 1 PU (The skin appears reddened and does not blanch (lose color briefly) and one unstageable PU (Unstageable pressure injury is a term that refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar.).
Review of the medical record showed an order for weekly skin assessments every Tuesday night dated 4/27/21.
Review of the hospice providers notes showed no documentation of the resident's skin condition.
During an interview on 12/16/21 at 2:41 P.M. the hospice provider said:
-The resident was admitted to the facility under hospice care.
Review of the medical record from 5/9/21 through 8/20/21 showed weekly wound assessments.
Review of the medical record showed the following wound assessments in August 2021:
-8/5/21: left heel measured 3.5 centimeters (cm) by 4.0 cm by 0.1 with no undermining (Undermining is caused by erosion under the wound edges, resulting in a large wound with a small opening) and no tunneling (A tunneling wound is a wound that's progressed to form passageways underneath the surface of the skin). Yellow slough present (Slough (also necrotic tissue) is a non-viable fibrous yellow tissue (which may be pale, greenish in color or have a washed out appearance) formed as a result of infection or damaged tissue in the wound) with scant amount of drainage, purulent (Purulent drainage is a sign of infection. It's a white, yellow, or brown fluid and might be slightly thick in texture). New orders for Vasche (a Wound Solution is intended for use in cleansing, irrigating, moistening and debriding acute and chronic wounds) soaked four by four to the wound bed, cover with ABD (a thick type of dressing), secure with Kerlex (Antimicrobial Large Roll Dressing is indicated for use as a primary dressing for exuding wounds) and secure with tape.
-8/12/21: left heel measured 4 cm by 6 cm by 0.1 with no undermining, no tunneling, yellow to black slough, 10% yellow slough and 90% black slough. Serosanguinous drainage (is a thin, watery fluid that is pink in color due to the presence of a small amount of red blood cells);
-8/20/21: left heel measured 4 cm by 6 cm by 0.1 cm, no tunneling, 100% black necrotic (dead) tissue.
Review of the medical record after 8/20/21 through 11/28/21 showed no documentation of the weekly wound assessments.
During an interview on 12/9/21 at 2:00 P.M., the former Director of Nursing (DON) said:
-The facility did not have a wound nurse to complete the weekly wound assessments due to lack of staff;
-He/she had not done any wound assessments.
During an interview on 12/10/21 at 12:42 P.M. LPN D said:
-He/she was promoted to the wound nurse in August 2021, but had not received any training;
-He/she only did wounds one time, then was pulled to the floor to work, and never assessed the wounds again;
-He/she resigned as the wound nurse a few weeks after he/she had been promoted due to not being able to function as the wound nurse;
-The resident did have a wound to the left heel. The wound on the coccyx was looking better
-The wound nurse does the weekly wound assessments, but since the facility does not have a wound nurse, no assessments have been completed.
During an interview on 12/13/21 at 7:55 A.M. a Hospice LPN A said:
-He/she had seen the resident and had done wound care;
-The hospice nurses would do the wound treatments several times a week;
-Hospice would direct the wound care, but it is the facility's responsibility to assess, measure and document on the wound and care for the wound when hospice did not come;
-The facility did not have a wound care team.
During an interview on 12/14/21 at 3:22 P.M. LPN E said:
-Wound assessments are completed by the wound nurse, but the facility does not had a wound nurse, so no wound assessments have been done.
During an interview on 12/14/21 at 3:30 P.M., the former Administrator said:
-The facility was short staffed on nurses and had to pull the wound nurse to work the floor;
-The facility did not have a dedicated wound nurse to complete the wound assessments;
-She would have expected the nurses to complete the wound assessments.
During an interview on 12/15/21 at 10:05 A.M. Physician B said:
-He was the resident's physician;
-He was aware of the wounds to the residents left foot;
-The resident had the wound on the left heel for a long time;
-He would have expected the facility to complete the wound assessments and to document the status of the wound.
2. Review of Resident #52's quarterly MDS, dated [DATE], showed:
- BIMS of 00 which indicated severe cognitive impairment;
- Total dependence for staff assistance for all activities of daily living (ADLs);
- Diagnoses of Alzheimer's disease, stroke, Parkinson's disease, one sided paralysis, malnutrion, metabolic encephalopathy (a problem in the brain), oropharyngeal dysphagia (a subjective sensation of difficulty or abnormality of swallowing), Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Dead tissue present on some parts of the wound bed, often includes undermining and tunneling).
- Skin and ulcer treatment included pressure reducing devices for chair and bed, turning and repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings other than to feet, applications of ointments or medications other than to feet.
Review of the resident's undated care plan, reviewed on 12/22/21, showed:
- The resident has a pressure ulcer to left buttock; abrasion to right side of the back; left temple skin grown came off. Interventions included:
o
Administer medications as ordered. Monitor/document for side effects and effectiveness.
o
Administer treatments as ordered and monitor for effectiveness.
o
Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician.
o
Follow facility policies/protocols for the prevention/treatment of skin breakdown.
o
If he/she refuses treatment, confer with him/her, interdisciplinary team and family to determine why and try alternative methods to gain compliance. Document alternative methods.
o
Inform his/her/family/caregivers of any new area of skin breakdown.
o
Monitor dressing to ensure it is intact and adhering. Report loose dressing to Treatment nurse.
o
Monitor nutritional status. Serve diet as ordered, monitor intake and record.
o
Monitor skin integrity per skin sweep schedule, with daily cares, shower day and PRN
o
Requires low air loss mattress per manufactures guidelines. Position with pillows or wedges
o
Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated.
o
Protective boots for pressure relief
o
Ready Care/med pass as ordered for wound healing
o
Uses cushion to wheelchair
o
Vitamin supplements as ordered for wound healing, see medication administration record (MAR)
o
Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate
o
Contracted wound care provider to evaluate and treat.
Review of the resident's weekly wound assessment showed:
- No weekly wound assessments found in the resident's electronic medical record (EMR) between 8/19/21 and 10/6/21;
- 10/6/21 at 2:00 P.M.: Wound details: date of onset 7/14/21; facility acquired; left buttocks; Stage IV pressure; 1.0 cm x 1.5 cm x 0.5 cm with 1 cm 12-12 undermining and no tunneling; wound bed color red; no drainage; no odor; normal wound edges; no pain related to the wound; stable wound healing progression.
- 10/13/21 at 1:23 P.M. Wound details: date of onset 7/14/21; facility acquired; left buttocks; Stage IV pressure; 1.0 cm x 1.5 cm x 0.3 cm with 0.8 cm 12-12 undermining and no tunneling; wound bed color pink; moderate drainage serosanguineous; no odor; normal wound edges; no pain related to the wound; improved wound healing progression.
- No other weekly wound assessments in the resident's EMR after 10/13/21.
During an observation on 12/9/21 at 11:26 A.M. showed:
-LPN A removed the bandage from Resident #52's left gluteal fold;
-The PU was the size of a half dollar, with an opening in the middle of the wound, the area around the wound was pink with no drainage and no odor;
-LPN A cleansed the wound with wound cleanser, applied Santyl (an ointment used to remove dead tissue from a wound) around and inside of the wound, then put gauze covered with Calcium alginate (a type of guaze used to remove dead tissue from a wound) inside of the wound and covered with border gause.
Review of the resident's December 2021 POS showed:
- Contracted wound provider to evaluate and treat; order dated 4/22/21;
- Weekly skin sweeps, every night shift every Wednesday; order dated 4/7/21;
- Lidocaine ointment 5%; apply to left buttock topically; order date 6/9/21;
- Collagenase ointment, 240 units per gram, apply to left gluteal fold; order date 10/5/21;
- The POS did not include orders for Santyl or calcium alginate.
During an interview on 12/9/21 at 11:30 A.M. LPN A said:
-The resident has had the PU to the left gluteal fold for a long period of time;
-He/she has not measured the wound, this is done by the wound nurse, but the facility does not have a wound nurse at this time;
-He/she has been treating the wound for a while, and can tell that the wound is healing.
During an interview on 12/14/21 at 3:15 P.M. LPN I said they did have a wound nurse, then he/she left and did not have one. If staff had any wound concerns they would put paperwork under the DON's door. Any wound documentation would be done by the wound nurse. Nurses on the floor do not do wound documents. Nurses would do the skin assessments. Most are done on the night shift.
During an interview on 12/14/21 at 4:15 P.M., Corporate Nurse A said they only had two residents in the building who had pressure ulcers. Those residents received services from the contracted wound provider. Those records, along with the weekly wound assessments, should be in the resident's EMR.
During an interview on 12/22/21 at 4:00 P.M., LPN A said charge nurses do not do the weekly wound assessments. The wound nurse is responsible for completing those. Charge nurses do the treatments for Resident #52 as ordered.
Review of the resident's EMR on 12/22/21 showed no documentation from the contracted wound care provider to show they saw the resident and no documentation of any weekly wound assessments since October 2021.
During an interview on 12/22/21 at 3:52. P.M., the MDS coordinator said they have two residents who receive wound care from the contracted wound provider, with Resident #52 being one. She did not know who had access to those records, documentation and recommedations. She thought the DON did, but they have had several DONs over the past few months so she did not know if anyone had reviewed the records.
During an interview on 12/22/21 at 4:22 P.M, the DON, Corporate Nurse B and the administrator said the contracted wound provider had an online portal for their wound care records. The administrator did not know who had access to the online portal. Corporate Nurse A said the MDS coordinator should have access to those records.
3. During an interview on 12/22/21 at 4:22 P.M. the Director of Nursing and Corporate Nurse said:
- It is her expectation that the charge nurses complete the weekly skin check. The weekly skin check should consist of the actual wound measurements. Weekly skin check is triggered in electronic medical record (PCC) schedule. If the wound is abnormal or deteriorates then the nurse should notify the physician;
- If there is no wound nurse, then the DON, charge nurse or the nurse manager is responsible for wound documentation.
During an interview on 12/23/21 at 8:00 A.M. Physician A said:
- He would expect the nurses to follow the facility policies for skin assessments and wound documentation.
MO194329
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to treat one sampled resident (Resident #97) with dignity when they did not clean the resident up after he/she was incontinent of bowel and staf...
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Based on observation and interview, the facility failed to treat one sampled resident (Resident #97) with dignity when they did not clean the resident up after he/she was incontinent of bowel and staff served him/her lunch while he/she sat in the bowel movement. The facility census was 104.
Review of the facility policy titled Resident Rights dated 11/1/2021 included the following:
- The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
-The resident has a right to be treated with dignity and respect including the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.
1. Review of Resident #97's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/18/21 showed the following:
- Brief Interview for Mental Status (BIMS) score was a 10 (indicates moderate cognitive impairment)
- Required one person for supervision with toileting and transfers.
- Ambulated with a walker.
- Always continent of bowel and bladder.
Observation on 12/9/21 at 11:55 A.M. showed Resident #97 sitting up in his/her bed eating ice chips. The resident said he/she was sitting in bowel movement and he/she had been having diarrhea all night. The resident said he/she had been sitting in the bowel movement for two hours. He/she knows how long it has been because he/she has a clock on the wall across from his/her bed. He/she put his/her light on and a staff person came in and he/she told the staff person he/she was dirty. The staff person turned the resident's call light off and said he/she would take care of it. The resident said that was an hour and a half ago.
Observation on 12/9/21 at 12:20 P.M. showed Registered Nurse (RN) A served the resident his/her lunch tray. The resident said to the staff person that he/she wanted more ice. The staff person told the resident he/she would get it after he/she finished passing lunch trays.
During an interview on 12/15/21 at 11:34 A.M., Resident #97 said he/she did not like having to eat his/her lunch while sitting in bowel movement. He/she did not tell the aide who brought his/her meal that he/she was dirty. He/she told a staff person earlier and he/she did not get cleaned up at that time.
During an interview on 12/9/21 at 2:00 P.M., RN A said he/she passed the resident his/her lunch tray. He/she did not know the resident was dirty when he/she passed the tray. The staff who answered his/her call light should have immediately cleaned the resident up.
During an interview on 12/9/21 at 2:30 P.M., the Director of Nursing said she would expect staff to immediately clean the resident up after being incontinent and the resident should never have had to eat his/her meal while sitting in bowel movement.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents or their representatives had the righ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents or their representatives had the right to participate in the development and implementation of the residents' person-centered plan of care when staff did not invite two of 24 sampled residents (Residents #66 and #84) or their families to attend scheduled meetings to develop a plan of care based on the residents' comprehensive assessments. The facility census was 104.
Review of the facility policy for Resident Rights dated 11/1/21 showed:
-The resident has the right to be informed of, and participate in, his or her treatment, including the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. The right to be informed, in advance, of changes to the plan of care. The right to receive the services and/or items included in the plan of care. The right to see the care plan, including the right to sign after changes to the plan of care.
1. Review of Resident #66 comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 10/27/21 showed:
-Unable to determine language, needs an interpreter;
-Cognitively impaired;
-Diagnoses of Alzheimer's, dementia, Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people. It is associated with degeneration of the basal ganglia of the brain and a deficiency of the neurotransmitter dopamine), anxiety, depression and Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).
During an interview on 12/14/21 at 12:48 P.M. Family Member (FM) B said:
-He/she is the resident's power of attorney and has not been invited to any care plan meetings;
-He/she has contacted the facility regarding the resident's inability to speak English and has offered to assist the facility in preparing a picture board to help with communication. He/she has not been contacted by anyone at the facility to set up a meeting to do this for the resident.
Review of the residents medical record on 12/20/21 at 3:58 P.M. showed:
-No documentation of the family being invited to the care plan meeting
2. Review of Resident #84's quarterly MDS dated [DATE] showed:
-Unable to answer questions, cognitively impaired;
-Diagnoses of hypertension, diabetes, stroke, aphasia (inability to speak), anxiety and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality).
During an interview on 12/14/21 at 12:48 P.M. FM A said:
-He/she has not been invited to any care plan meeting since the resident has been admitted to the facility.
Review of the resident's medical record on 12/20/21 at 3:58 P.M. showed:
- No documentation of the family being invited to the care plan meetings.
3. During an interview on 12/21/21 at 3:33 P.M. the MDS Coordinator said;
-The Social Services Director was in charge of notifying the family and inviting them to the care plan conference;
-The facility does not have a Social Services Director;
-No one has been inviting the resident families or responsible parties to the care plan meetings since the Social Services Director resigned a few months ago.
During an interview on 12/22/21 at 4:22 P.M. the Director of Nursing and Corporate Nurse B said:
-The MDS coordinator is responsible for inviting the family to the care plan meetings and documenting the invitation on a calendar;
-The MDS coordinator should keep the letter of the invitation and upload the invitation in electronic medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #86's quarterly MDS dated [DATE] showed:
-BIMS of 11, which shows some difficulty with new situations;
-In...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #86's quarterly MDS dated [DATE] showed:
-BIMS of 11, which shows some difficulty with new situations;
-Independent with cares;
-Diagnoses of seizure disorder, bipolar (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks).
Review of the diet order showed an order for a Regular diet.
Observation on 12/16/21 at 12:35 P.M. showed:
-The resident was served a hamburger patty covered with gravy, scalloped potatoes, mixed vegetables and fruit cocktail;
-The resident at 25% of the meal, he/she did not eat the mixed vegetables, a few bites of the hamburger patty and a few bites of the scalloped potatoes.
During an interview on 12/16/21 at 12:35 P.M. the resident said:
-He/she does not like vegetables, he/she does not get a choice of foods at meal times;
-He/she does not like beans but will eat corn;
-No one has talked with him/her about what food he/she likes or dislikes.
Review of the medical records showed no dietary assessment for the resident's food preferences. A dietary card for the resident was not available.
During an interview on 12/10/21 at 10:20 A.M. the R.D. said:
-Residents preferences should be honored.
2. Review of Resident #42's admission Minimum Data Set (MDS), dated [DATE], showed:
- A Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment;
- Independent with all activities of daily living (ADLs);
- Diagnoses included non-pressure chronic ulcer, orthopedic aftercare-surgical amputation, absence of right toe, hydronephrosis with renal/ureteral calculous obstruction (a condition characterized by excess fluid in a kidney due to a backup of urine), acute osteomylitis (inflammation of bone caused by infection, generally in the legs, arm, or spine) of the right ankle/foot, body mass index of 40.0 to 44.9, and low back pain. The resident had no mental disabilities or intellectual diagnoses.
Review of the 11/18/21 nutrition/dietary note, written by the registered dietitian (RD), showed diet order remains regular with diabetic precautions. Documented meal intakes are good. No dietary notes indicated staff spoke with the resident about his/her preferences.
During an interview on 12/10/21, at 3:10 P.M., the dietary manager said he tried to keep different foods on hand for residents who did not want to eat the main meal each day. He had one resident who liked grilled chicken so he tried to always keep it on hand for him/her. They had several residents who were picky and who wanted what they want. The cooks should be serving the residents what they have on their tickets.
Review of the resident's order summary report printed on 12/16/21, showed:
- Regular diabetic precautions diet, regular texture.
Review of the resident's current care plan, printed on 12/16/21, showed:
- Residents' rights are guaranteed by the Federal 1987 Nursing Home Reform Law which requires skilled nursing facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity and self-determination. Interventions included having the right to make independent informed choices such as personal decisions; request reasonable accommodation of needs and preferences;
- The resident has diabetes mellitus. Interventions included: dietary consult for nutritional regimen and ongoing monitoring; monitor/document/report as needed compliance with diet and document any problems; offer substitutes for foods not eaten.
- The resident has a nutritional problem or potential nutritional problem related to obesity and diabetes. Interventions included: provide and serve diet as ordered.
During an interview on 12/15/21. at 10:18 A.M., the resident said the food at the facility is not good. It is cold, and just does not taste good. Meals are always late. He/she is a very picky eater. They had a care plan meeting and he/she voiced his/her concern about the food choices and that he/she liked having grilled chicken. The dietary manager (DM) told him/her I got you but he does not got me. He/she really likes grilled chicken and the DM said he would always have grilled chicken available for him/her. When the resident requests it, the cooks will tell him/her they do not have it. The snacks they serve are not good. They have no fresh fruit and if you want to have a snack, it is all junk food.
During an interview on 12/15/21 at 10:28 A.M., the resident said since he/she is diabetic, he/she would like to have more of a diabetic diet but he gets full sugar Koolaid. They do not offer any low sugar options unless it is water.
Observation and interview on 12/21/21 at 4:17 P.M. the resident said he/she does not feel well. He/she has been sick to his/her stomach and has had diarrhea. He/she found out yesterday he/she has a gallstone. He/she did not receive the grilled chicken he/she wanted for lunch today and he/she is afraid to eat anything else. The resident's lunch tray still remained untouched in his/her room. The tray did not include the grilled chicken the resident requested.
During an interview on 12/10/21 at 10:20 A.M. the R.D. said:
-Residents preferences should be honored.
Based on observation, interview, and record review, the facility failed to create an environment respectful of the rights of a resident to make choices about aspects of his/her life, when the facility failed to provide choices to two residents (Resident #42 and #86) in regard to food preferences and failed to offer one resident (Resident #89) visitation, when they prevented the resident from visiting with his/her spouse. The facility census was 104.
Review of the undated Resident's Handbook Appendix 1 showed:
- Statement of Resident Rights, under Federal Law, Right to Self-Determination:
--Have a choice of activities, schedules, health care, and providers;
--Reasonable accommodation of needs and preferences.
Review of the facility's Resident Rights policy dated 11/1/21 included the following information:
- The facility will inform the resident both orally and in writing in a language the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.
- The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
- The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights.
The facility did not provide a visitation policy for the facility.
1. Review of Resident #89's admission Minimum Data Set (MDS), a federally mandated resident assessment completed by facility staff, dated 11/9/21 included the following information:
- The resident's Brief Interview of Mental Status showed a score of 15 which indicates the resident is cognitively intact.
During an interview on 12/9/21 at 2:30 P.M., Resident #89 said his/her spouse stayed late one evening with him/her. When the spouse tried to come back the next day, he/she was told he/she could not visit the resident and he/she was trespassing. The resident's spouse did not leave willingly the evening he/she stayed with the resident and the facility staff called the police and the police came and removed the spouse from the facility. Neither his/her spouse or another family member could visit him/her.
During an interview on 12/9/21 at 4:30 P.M., the Director of Nursing (DON) said he was working when the resident's spouse was made to leave. The spouse was very disruptive and he thought the spouse may have been tweaking. He did not think the spouse should be allowed to visit due to being disruptive. He had not done anything to facilitate a visit with the spouse and resident. The resident told him he/she did not want to see the spouse or the other family member.
During an interview on 12/9/21 at 3:15 P.M., the facility administrator said she was aware the resident's spouse could not visit. She said the resident was disruptive. She has not done anything to facilitate the resident being able to see his/her spouse. She was aware the resident wanted to see his/her spouse. She would talk with the resident about being able to visit with his/her spouse and come up with a solution so the spouse could visit.
During an interview on 12/10/21 at 11:40 A.M., the resident said no one from the facility had talked with him/her about his/her spouse being unable to visit. He/she wanted to see his/her spouse and family member. He/she would have to move if he/she did not get to see his/her spouse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to allow one of 24 sampled residents (Resident #42) access to his/her medical record when he/she requested. The facility census was 104 at the...
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Based on interview and record review, the facility failed to allow one of 24 sampled residents (Resident #42) access to his/her medical record when he/she requested. The facility census was 104 at the time of the survey.
Review of the facility's Resident Handbook, revised 2018, showed:
- Statement of Resident Rights: Right to Self-Determination:
*Choice of activities, schedules, health care and providers;
*Reasonable accommodations of needs and preferences;
- Right of Access to:
*Personal and medical records;
- Rights under State law, including:
*The right to be adequately informed of your medical condition and proposed treatment, unless otherwise indicated by your physician, and to participate in planning of all medical treatment, including the right to refuse medication and treatment, unless otherwise indicated by your physician, and to know the probable consequences of such actions;
*The right to review and obtain copies of your medical records.
Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/11/21, showed:
- A Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment;
- Independent with all activities of daily living (ADLs);
- Diagnoses included non-pressure chronic ulcer, orthopedic aftercare-surgical amputation, absence of right toe, hydronephrosis with renal/ureteral calculous obstruction (a condition characterized by excess fluid in a kidney due to a backup of urine), acute osteomylitis (inflammation of bone caused by infection, generally in the legs, arm, or spine) of the right ankle/foot, body mass index of 40.0 to 44.9, and low back pain. The resident had no mental disabilities or intellectual diagnoses.
Review of the resident's demographics admission record, printed on 12/16/21, showed the facility listed the resident as his/her own responsible party.
Review of the resident's care plan showed an undated focus area which stated the resident is independent for meeting emotional, intellectual, physical and social needs.
During an interview on 12/13/21 at 4:30 P.M., the resident said he/she had asked the Marketing Director, who was acting as social services, to send his/her medical information to another facility in the area because he/she did not wish to live at the facility any longer. The other facility had a Medicaid bed available for him/her, but had never received any information regarding the resident so they gave the bed to someone else. When the resident tried to talk to the Marketing Director about this, he would repeatedly say I got you; I got you. The resident requested that the Marketing Director show him/her what information he sent to the other facility, but the Marketing Director said he could not because it had doctor stuff in it and the resident would not understand it. This made the resident feel belittled and not listened to. He/she does not believe the Marketing Director sent any of the paperwork to the other facility.
Review of the resident's interdisciplinary progress notes showed no notes regarding the resident's desire to move to a different facility or the resident's request to see his/her medical records.
During an interview on 12/20/21 at 4:10 P.M., the Marketing Director said he sent the referral to the facility the resident requested and actually sent it twice. He did not keep a copy of what he sent. He sent it from the fax machine upstairs. He does not have a transmittal to say that they received the information. He did not call the facility to be sure they received it. He only sent the face sheet and the medication list. He did not document anywhere to show he sent it. He did not remember the resident asking to see the information he sent, but did not know what the process was for allowing residents to review their medical records.
During an interview on 12/22/21 at 4:00 P.M., the Administrator said social services usually takes care of helping residents see their medical records. It is their record so there should not be an issue unless the resident has a guardian who has given direction to not allow the resident to see the record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to clarify the status of one sampled resident's (Resident #84) advance...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to clarify the status of one sampled resident's (Resident #84) advanced directive and code status out 24 sampled residents. The facility census was 104 residents.
The facility did not provide a policy for Advanced Directives.
Review of Resident #84's electronic medical record (EMR) showed:
- A referral packet dated [DATE] from the sending facility that indicated the resident was a full code (which means that cardiopulmonary resuscitation (CPR) to be done if the resident's heart stopped beating).
-No Durable Power of Attorney (DPOA) on file;
-No out of hospital DNR (Do Not Resuscitate) paperwork on file.
Review of care plan for DNR code status dated [DATE] showed:
-The resident has a DNR code status;
-Goal: He/she and the DPOA will be informed of the the right to complete advance directives to direct medical care and make treatment goals known;
-Interventions: Advance Directives and the residents wishes will be honored; Advanced Directives completed and placed in the front of the chart to ensure timely access and a copy placed in the financial records.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated [DATE] showed the resident had a BIMS (Brief Interview for Mental Status of zero, which means the resident is not able to answer questions.
Review of the resident's EMR showed no letter of incapacitation (Incapacitated person means any person who is impaired to the extent that he lacks sufficient understanding or capacity to make or communicate).
Review of the residents Physician's Orders (POS) showed the resident was a DNR.
Review of the Medication Administration Record (MAR) dated [DATE] through [DATE] showed the resident was a DNR.
During an interview on [DATE] at 12:13 P.M. the Medical Records personnel said:
-The resident is a DNR, but there is no DPOA or out of hospital DNR in the resident's medical record;
-He/she does not take care of the DPOA's or out of hospital DNR. The Social Services Director (SSD) took care of this, and the facility no longer has a SSD.
-The referral packet dated [DATE] that is in the resident's medical record has the resident as a full code.
Review of the DNR book for the residents who reside on Village, showed no DNR paperwork for Resident #84.
During an interview on [DATE] at 2:00 P.M., Licensed Practical Nurse (LPN) D said:
-There is a DNR book on each hall that has the DNR information for each resident;
-On [DATE] when he/she sent the out to the hospital none of the printers were working so the Director Of Nursing (DON) told him/her to send the only out of hospital DNR with the resident to the hospital.
During an interview on [DATE] at 2:30 P.M. LPN E said:
-The resident does not have an out of hospital DNR or DPOA paperwork in his/her medical record;
-He/she has asked the hospital to send them the paperwork.
During an interview on [DATE] at 9:00 A.M. the Administrator said;
-The resident's DPOA has brought in the out of hospital DNR.
-The marketing director is working with the DPOA on the letters of incapacitation;
-The DNR paperwork should be in the resident's medical record.
During an interview on [DATE] at 4:22 P.M. the DON and Corporate Nurse B said:
-The SSD, Unit manager, Administrator and DON usually checks the medical record for the DNR;
-The SSD should follow up with the family for the DPOA and DNR if this information is not in the medical record.
-If there is no DNR in the resident's record, then the resident is a full code.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #66's comprehensive MDS dated [DATE] showed:
-The resident unable to answer questions;
-Unable to determin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #66's comprehensive MDS dated [DATE] showed:
-The resident unable to answer questions;
-Unable to determine language spoken;
-Physical behaviors of one to two days per week;
-Extensive assistance of one staff member for Activities of Daily Living (ADL's);
-Diagnoses of Alzheimer's disease, dementia, Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), anxiety, depression and Schizophrenia ( is a serious mental disorder in which people interpret reality abnormally).
Review of the undated care plan for communication showed:
-Focus: The resident has a communication problem related to a language barrier. The resident is not able to read Korean (not able to read);
-Goal: The resident will be able to make basic needs known on a daily basis.
-Interventions/Tasks: Anticipate and meet needs; be conscious of residents position when in groups, activities, dining room to promote proper communication with others.
Review of the undated care plan for behaviors showed:
-Focus: the resident has been physically aggressive related to dementia. Wanders on a secure unit, is resistive to care; aggressive towards peers at times;
-Goal: The resident will demonstrate effective coping skills and will not harm self or others;
-Interventions/Tasks: When the resident becomes agitated offer him/her cereal, noodles or peanut butter and jelly sandwiches. 11/12/21: this intervention has proven effective and his/her agitation has decreased. Continue to offer him/her foods of his/her liking if he/she becomes agitated/restless.
--10/25/21 when the resident becomes agitated: intervene before agitation escalates. Guide away from the source of distress; encourage calmly in conversation, if response is aggressive, staff to walk calmly away, and approach later;
-11-13-21: staff witnessed the resident grabbing another resident's scarf that was around the other resident's neck, pulling on it. Immediately separated them and started one on one. The resident refused to stay in his/her room and wandered the hall, talking loudly in his/her language. He/she pulled his/her things out into the hallway. Physician gave order to send the resident for a psychiatric evaluation. The resident sent to the hospital. The resident returned from the hospital due to not meeting criteria since the behavior was dementia related.
-Administer medication as ordered. Assess and address for contributing sensory deficits. Communication: provide physical and verbal cues to alleviate anxiety. Monitor frequently
3. Review of Resident #74's quarterly MDS dated [DATE] showed:
-BIMS of 5, unable to make decisions;
-Independent with ADL's;
-Diagnoses of Alzheimer's disease, psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), depression.
Review of the undated care plan for behaviors showed:
-Focus: the resident has a potential for behavior problems related to Alzheimer's, depression and psychosis. Will wander on a secure unit, will take things out of other's room, carries around a baby doll and becomes agitated if someone tries to take it from him/her;
-Goal: The resident will have no evidence of behavior problems;
-Interventions/Tasks: Administer medication as ordered; anticipate and meet her needs; caregivers to provide opportunity for positive interactions, attention. Stop and talk with him/he as passing by; encourage him/her to express feelings appropriately; if reasonable, discuss his/her behaviors. Explain/reinforce why behavior is inappropriate and/or unacceptable; intervene as necessary, divert attention, remove from situation and take to alternate location as needed. He/she carries a baby doll around. Psychiatry consults as needed.
On 12/20/21 at 11:30 A.M. the administrator reported she was just made aware of a resident to resident interaction that occurred on 12/19/21 involving Resident #66 and Resident #74. This morning LPN D, said that he/she had overheard a housekeeper which housekeeper talking about the incident She is in the process of investigating.
Review of the medical record on 12/20/21 at 12:00 P.M. showed a nurses note signed by LPN D:
-On 12/20/2021 at 9:32 A.M. Incident Note- This writer was alerted by housekeeper A at about 8:40 A.M. that there was a physical altercation yesterday with this resident (Resident #74) and another resident. He/she stated he/she alerted the nurse and the residents were separated. This writer asked the housekeeper to write a statement. Informed the administrator of the incident.
Review of the Resident #66 and Resident #74's medical record showed no documentation of the resident to resident interaction.
During an interview on 12/20/21 at 12:30 P.M. LPN D said:
-The incident was reported to him/her by housekeeper A. Resident #66 attacked Resident #74 over the baby doll. He/she was not told about this in report this morning and there is nothing in the medical record He/she reported the incident to the Administrator this morning.
During an interview on 12/20/21 at 2:09 P.M. Housekeeper A said:
-He/she worked on Sunday, 12/19/21. Resident #74 had the baby doll, Resident #66 was sitting across the table from Resident #74. Resident #66 wanted the baby doll and Resident #74 would not give him/her the doll. Resident #66 began to hit Resident #74, hitting him/her with an open hand. He/she yelled for the nurse who came and told Resident #66 to sit down as Resident #66 was screaming. He/She walked Resident #74 to his/her room. Resident #74 was not hurt. The nurse came to the dining room when he/she yelled for him/her and tried to talk to Resident #66.
During an interview on 12/20/21 at 4:00 P.M. the Administrator said:
-The nurse who was working the secured unit at the time of the resident to resident interaction on 12/19/21 was an agency nurse. Several attempts were made to call the agency nurse. Was unable to leave a voice message.
-She is aware that all resident to resident interactions considered abuse, should be investigated immediately, and should be reported to the state licensing agency.
Based on interview and record review, the facility failed to ensure staff immediately reported to the Department of Health and Senior Services (DHSS) any and all allegations of abuse, neglect, exploitation or mistreatment. The facility failed to immediately report an allegation of sexual abuse for one of 24 sampled residents (Resident #88) and allegation of resident to resident abuse for two sampled residents (Residents #66 and #74). The facility's census was 104.
Review of the facility's Abuse, Neglect and Exploitation policy, implemented on 11/1/21, showed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy included:
- Policy Explanation and Compliance Guidelines:
1. The facility will develop and implement written policies and procedures that:
a. Prohibit and prevent abuse, neglect, and exploitation of residents;
b. Establish policies and procedures to investigate any such allegations, and
c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention and;
2. The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect or exploitation to the state survey agency and other officials in accordance with state law.
3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.
- Employee training:
C. Training topics will include:
4. Reporting process for abuse, neglect, exploitation and misappropriation of resident property, including injuries of unknown sources;
- Reporting/Response: . The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes;
a. Immediately, but not later than two (2) hours after the allegation is made, if events that cause the allegation involve abuse or result in serious bodily injury, or
b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious injury;
- The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, to report the results of the investigation within five (5) working days of the incident as required by state agencies.
1. Review of Resident #88's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/9/21, showed:
- A Brief Interview for Mental Status of 15, indicating the resident had no cognitive impairment;
- Exhibited behaviors not directed toward others, such as hitting, scratching self; pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds, one to three days during the assessment period;
- Independent with bed mobility, moving on and off the nursing unit, eating, personal hygiene; supervision with toilet use, dressing and transferring from one surface to another;
- Diagnoses included stroke, heart failure, high blood pressure, renal insufficiency, viral hepatitis, one sided paralysis, anxiety, depression, psychoactive substance abuse (alcohol), atrial flutter (a type of abnormal heart rhythm), palliative care, ischemic cardiomyopathy (the heart's ability to pump blood is decreased because the heart's main pumping chamber, or left ventricle, is enlarged, dilated and weak), and paroxysmal tachycardia (a type of irregular heartbeat).
- The resident suffered a condition or chronic disease that may result in a life expectancy of less than six months;
- Hospice care while a resident.
Review of the resident's current care plan showed the resident has a potential for a behavior problem:
- Manipulative, non-compliant with wearing LifeVest (a personal defibrillator worn by a patient at risk for sudden cardiac arrest, monitors the patient's heart continuously; and if the patient goes into a life-threatening arrhythmia, the LifeVest delivers a shock treatment to restore the patient's heart to normal rhythm), tends to exaggerate on things/details; Instigates trouble with peers; complaints/behaviors tend to escalate when he/she knows state surveyors are in the building; his/her stories are not consistent, makes false allegations;
- 11/17/21 refused to go to cardiologist appointment;
- 11/19/21 cancels appointments at times and will call hospice nurse if he/she does not get what he/she wants or fast enough;
- Attention seeking; will put him/herself on the floor.
- 12/21/21 provide care with two people present due to him/her making false accusations.
During an interview on 12/20/21 at 4:30 P.M., the resident said he/she had been having a sexual relationship with Licensed Practical Nurse (LPN) G. He/she did not have a relationship with LPN G prior to being admitted to the facility. This sexual relationship went on for a while. He/she he did not know this was considered abuse. The relationship ended when LPN G left his/her employment with the facility. One night, LPN G came into the facility, after going to a concert, and told the resident he/she wanted to fuck. LPN G was wasted and he/she did not want to since he/she was wasted. LPN G forced him/her to have sex that night. The resident had reported the relationship to the previous administrator and the Director of Nursing and they said they would take care of it. LPN G no longer works at the facility. He/she does not know if LPN G was terminated or if he/she quit. Other staff in the facility were aware of the relationship.
During an interview on 12/22/21 at 12:00 P.M., the Administrator said she had just been made aware of the resident reporting he/she had been involved in a sexual relationship with a staff member. She did not know anything about this or if it had been investigated, but would be contacting the previous administrator to see what she was aware of.
During an interview on 12/22/21 at 12:48 P.M. the Administrator said she had contacted the previous administrator. She was aware of the allegations and would send what information she had on the investigation. She is still trying to get the investigation completed. She did not know why LPN G left employment with the facility. They have no human resources staff and they cannot find his/her employee file. She did not know why the previous administrator or director of nursing did not report the allegations to the state survey agency.
Calls to LPN G were not returned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff immediately begin an investigation into allegations of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff immediately begin an investigation into allegations of abuse, neglect, exploitation or mistreatment, when staff received an allegation of sexual abuse for one of 24 sampled residents (Resident #88) and allegation of resident to resident abuse for two sampled residents (Residents #66 and #74). The facility's census was 104.
Review of the facility's Abuse, Neglect and Exploitation policy, implemented on 11/1/21, showed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy included:
- Investigation of alleged abuse, neglect and exploitation:
A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.
B. Written procedures for investigations include:
1. Identifying staff responsible for the investigation;
3. Investigating different types of alleged violations;
4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;
6. Providing complete and thorough documentation of the investigation.
1. Review of Resident #88's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/9/21, showed:
- A Brief Interview for Mental Status of 15, indicating the resident had no cognitive impairment;
- Exhibited behaviors not directed toward others, such as hitting, scratching self; pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds, one to three days during the assessment period;
- Independent with bed mobility, moving on and off the nursing unit, eating, personal hygiene; supervision with toilet use, dressing, and transferring from one surface to another;
- Diagnoses included stroke, heart failure, high blood pressure, renal insufficiency, viral hepatitis, one sided paralysis, anxiety, depression, psychoactive substance abuse (alcohol), atrial flutter (a type of abnormal heart rhythm), palliative care, ischemic cardiomyopathy (the heart's ability to pump blood is decreased because the heart's main pumping chamber, or left ventricle, is enlarged, dilated and weak), and paroxysmal tachycardia (a type of irregular heartbeat).
Review of the resident's current care plan showed the resident had the potential for a behavior problem:
- Manipulative, tends to exaggerate on things/details; Instigates trouble with peers; complaints/behaviors tend to escalate when he/she knows state surveyors are in the building; his/her stories are not consistent, makes false allegations;
- Attention seeking; will put him/herself on the floor.
- 12/21/21 provide care with two people present due to him/her making false accusations.
During an interview on 12/20/21 at 4:30 P.M., the resident said he/she had been having a sexual relationship with Licensed Practical Nurse (LPN) G. This sexual relationship went on for a while. He/she he did not know this was considered abuse. The relationship ended when LPN G left his/her employment with the facility. One night, LPN G came into the facility after going to a concert and told the resident he/she wanted to fuck. LPN G was wasted and he/she did not want to since he/she was wasted. LPN G forced him/her to do have sex that night. He/she had reported the relationship to the previous administrator and Director of Nursing and they said they would take care of it. LPN G no longer works at the facility; he/she did not know if LPN G was terminated or if he/she quit. Other staff in the facility were aware of the relationship.
Record review showed no investigation into the allegation of sexual abuse by LPN G to the resident.
During an interview on 12/22/21 at 12:00 P.M., the Administrator said she had just been made aware of the resident reporting he/she had been involved in a sexual relationship with a staff member. She did not know anything about this or if it had been investigated, but would be contacting the previous administrator to see what she was aware of.
During an interview on 12/22/21 at 12:48 P.M., the Administrator said she had contacted the previous administrator. She was aware of the allegations and would send what information she had on the investigation. She was still trying to get the investigation completed. She did not know why LPN G left employment with the facility. They had no human resources staff and they cannot find his/her employee file. She did not know why the previous administrator or director of nursing did not complete a thorough investigation of these allegations. Staff should not engage in sexual relationships with residents.
2. Review of Resident #66's comprehensive MDS, dated [DATE], showed:
-The resident unable to answer questions;
-Unable to determine language spoken;
-Physical behaviors of one to two days per week;
-Extensive assistance of one staff member for Activities of Daily Living (ADL's);
-Diagnoses of Alzheimer's disease, dementia, Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), anxiety, depression and Schizophrenia (is a serious mental disorder in which people interpret reality abnormally).
Review of the undated care plan for communication showed:
-Focus: The resident had a communication problem related to a language barrier. The resident was not able to read Korean anymore;
-Goal: The resident would be able to make basic needs known on a daily basis.
-Interventions/Tasks: Anticipate and meet needs; be conscious of residents position when in groups, activities, dining room to promote proper communication with others.
Review of the undated care plan for behaviors showed:
-Focus: the resident had been physically aggressive related to dementia. Wanders on a secure unit, was resistive to care; aggressive towards peers at times;
-Goal: The resident will demonstrate effective coping skills and will not harm self or others;
-Interventions/Tasks: When the resident becomes agitated offer him/her cereal, noodles or peanut butter and jelly sandwiches. 11/12/21: this intervention had proven effective and his/he agitation had decreased. Continue to offer him/her foods of his/her liking if he/she becomes agitated/restless. --10/25/21 when the resident becomes agitated: intervene before agitation escalates. Guide away from the source of distress; encourage calmly in conversation, if response was aggressive, staff to walk calmly away, and approach later;
-11-13-21: staff witnessed the resident grabbing another resident's scarf that was around the other resident's neck, pulling on it. Immediately separated them and started one on one. The resident refused to stay in his/her room and wandered the hall, talking loudly in his/her language. He/she pulled his/her things out into the hallway. Physician gave order to send the resident for a psych evaluation. The resident sent to the hospital. The resident returned from the hospital due to not meeting criteria since the behavior was dementia related.
-Administer medication as ordered. Assess and address for contributing sensory deficits. Communication: provide physical and verbal cues to alleviate anxiety. Monitor frequently
3. Review of Resident #74's quarterly MDS dated [DATE] showed:
-BIMS of 5, unable to make decisions;
-Independent with ADL's;
-Diagnoses of Alzheimer's disease, psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), depression.
Review of the undated care plan for behaviors showed:
-Focus: the resident had a potential for behavior problems related to Alzheimer's, depression and psychosis. Will wander on a secure unit, will take things out of other's room, carries around a baby doll and becomes agitated if someone tries to take it from him/her;
-Goal: The resident will have no evidence of behavior problems;
-Interventions/Tasks: Administer medication as ordered; anticipate and meet his/her needs; caregivers to provide opportunity for positive interactions, attention. Stop and talk with him/he as passing by; encourage him/her to express feelings appropriately; if reasonable, discuss his/her behaviors. Explain/reinforce why behavior is inappropriate and/or unacceptable; intervene as necessary, divert attention, remove from situation and take to alternate location as needed. He/she carries a baby doll around. Psychiatry consults as needed.
On 12/20/21 at 11:30 A.M., the administrator reported she was just made aware of a resident to resident interaction that occurred on 12/19/21 involving Resident #66 and Resident #74. This morning by LPN D, who said that he/she had overheard a housekeeper talking about the incident She was in the process of investigating the incident.
Review of a nurses note, dated on 12/20/2021 at 9:32 A.M., showed LPN D documented Incident Note- This writer was alerted by the housekeeper at about 8:40 A.M., that there was a physical altercation yesterday with this resident and another resident. He/she stated he/she alerted the nurse and the residents were separated. This writer asked the housekeeper to write a statement. I informed the administrator of the incident.
During an interview on 12/20/21 at 12:30 P.M., LPN D said:
-The incident was reported to him/her by the housekeeper. Resident #66 attacked Resident #74 over the baby doll. He/she was not told about this in report this morning and there was nothing in the medical record. He/she reported the incident to the Administrator this morning.
During an interview on 12/20/21 at 2:09 P.M., Housekeeper A said he/she worked on Sunday, 12/19/21. Resident #74 had the baby doll, Resident #66 was sitting across the table from Resident #74. Resident #66 wanted the baby doll and Resident #74 would not give him/her the doll. Resident #66 began to hit Resident #74, hitting him/her with an open hand. He/she yelled for the nurse who came and told Resident #66 to sit down as Resident #66 was screaming. He/She walked Resident #74 to his/her room. Resident #74 was not hurt.
During an interview on 12/20/21 at 4:00 P.M., the Administrator said:
-The Nurse who was working the secured unit at the time of the resident to resident interaction on 12/19/21 was an agency nurse. Several attempts were made to call the agency nurse. Was unable to leave a voice message.
-All resident to resident interactions that are considered abuse should be investigated immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow professional standards of practice when they d...
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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 professional standards of practice when they did not clarify with one of 24 sampled resident's (Resident #42) physician parameters staff should use to call with the resident's blood pressure readings and did not check one resident's (Resident #58) oxygen saturations to keep above 90%. The facility census was 104.
The facility did not provide a policy that addressed clarifying physician's orders.
Review of the Medication Administration policy, dated 11/1/21, showed the policy did not address clarifying physician orders.
Review of the American Heart Association's website, www.heart.org, showed:
- Normal systolic blood pressure (SBP) less than 120 and diastolic blood pressure (DBP) less than 80;
- Elevated SBP 120 to 129 and DBP less than 80;
- High blood pressure (hypertension) Stage 1 SBP 130 to 139
or DBP 80 to 89;
- High blood pressure (hypertension) Stage 2 SBP 140 or higher or DBP 90 or higher;
- Hypertensive crisis (consult your doctor immediately) SBP higher than 180 and/or DBP higher than 120.
1. Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/11/21, showed:
- A Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment;
- Independent with all activities of daily living (ADLs);
- Diagnoses included non-pressure chronic ulcer, orthopedic aftercare-surgical amputation, absence of right toe, hydronephrosis with renal/ureteral calculous obstruction (a condition characterized by excess fluid in a kidney due to a backup of urine), acute osteomyelitis (inflammation of bone caused by infection, generally in the legs, arm, or spine) of the right ankle/foot, body mass index of 40.0 to 44.9, and low back pain.
Review of the October 2021 TAR showed:
- Blood pressure/pulse weekly, every day shift every Saturday; notify physician if SBP less than 90 or greater than 200 or if heart rate (HR) is less than 50; start date 10/9/21.
Review of the November 2021 MAR showed:
- Amlodipine besylate (used to treat high blood pressure and chest pain) 5 milligrams (mg) give one table by mouth one time daily for high blood pressure; start date 10/5/21.
Review of the November 2021 TAR showed:
- Blood pressure/pulse weekly, every day shift every Saturday; notify physician if SBP less than 90 or greater than 200 or if heart rate (HR) is less than 50; start date 10/9/21.
Review of the resident's care plan, printed on 12/16/21, showed a focus area which read the resident has hypertension (high blood pressure, BP). Interventions/tasks included:
- 12/8/21: elevated BP and physician made aware. Added another BP medication, some labs, electrocardiogram (EKG), and chest x-ray; also gallbladder test. Monitor BP as ordered see treatment administration record (TAR).
- 12/9/21: Resident refused to take both of his/her BP medications together; physician faxed to change medication times;
- Avoid taking BP reading after physical activity or emotional distress;
- Give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a drop in blood pressure upon standing) and increased heart rate (tachycardia) and effectiveness;
- Monitor for and document any edema. Notify physician;
- Monitor/document/report as needed (PRN) any signs or symptoms of malignant hypertension (very high blood pressure that comes on suddenly and quickly): headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (dyspnea).
- Monitor/record use/side effects of medications; report to physician as necessary;
- Obtain blood pressure/pulse weekly and PRN or as ordered; see medication administration record (MAR).
Review of the interdisciplinary progress notes, dated 12/8/21 at 12:13 P.M., showed:
- Losartan Potassium tablet 100 milligram (mg), give one tablet by mouth one time a day for high blood pressure.
Review of the interdisciplinary progress notes, dated 12/8/21 at 5:29 P.M., staff documented:
- This morning at approximately 9:15 A.M., when doing the resident's COVID assessment, he/she asked if this writer could check his/her BP as he/she said his/her BP had been running high at his/her physician's appointments.
- BP checked and was 182/122, with a pulse of 82.
- Resident appeared in no distress, denied any radiating pain but did complain of a headache and right foot pain rating an 8 out of 10.
- Gave Norco (a pain medication) 5-325 mg 1 tablet at 9:20 A.M.
- Physician was in route to facility to do rounds so he would check on resident when here.
- Resident noted to take scheduled Amlodipine (a calcium channel blocker which can treat high blood pressure and chest pain) 5 mg so asked certified medication technician (CMT) to give his/her morning medications.
- Resident up to wheelchair propelling self about, visiting with staff and other residents.
- Retook BP again at 11:00 A.M. and was 166/118;
- Resident continues to appear with no distress and said headache was better since taking the Norco.
- Physician here at facility and assessed the resident and orders received to do EKG, chest x-ray 2-view, gallbladder ultrasound, repeat complete blood count with differential and complete metabolic panel in one month, do hemoglobin A1C and full lipids panel on 12/10/21.
- Start Losartan (can treat high blood pressure. It can reduce the risk of stroke in patients with high blood pressure and an enlarged heart. It can also treat kidney disease in patients with diabetes) 100 mg 1 tablet daily and check BP every shift for 14 days and report to the physician if abnormal.
- Losartan 50 mg 2 tablets obtained from Emergency medication kit and given at approximately 12:30 P.M.
- Resident then left facility to go to a nephrology (the subspecialty of internal medicine that focuses on the diagnosis and treatment of diseases of the kidney) appointment at approximately 1:00 P.M.
Review of the current physician's order sheet printed on 12/16/21, showed:
- BP check every shift for 14 days;
- Start date 12/8/21;
- End date 12/22/21;
- The order did not include instructions to call with any abnormal results and did not give any parameters of what was abnormal.
Review of the December 2021 MAR showed:
- Amlodipine besylate (used to treat high blood pressure and chest pain) 5 milligrams (mg) give one table by mouth one time daily for high blood pressure; start date 10/5/21.
- Losartan Potassium tablet 100 mg, give one tablet by mouth one time a day for high blood pressure; start date 12/9/21.
Review of the interdisciplinary progress notes, dated 12/9/21 at 10:13 A.M. showed:
- The resident refused to take his/her new blood pressure medication (losartan) with his/her other (amlodipine) together at the same time.
- The resident took losartan but not the other.
- The physician was faxed about changing the times of the medications so they are not given together.
Review of the December TAR showed as of 12/16/21:
- BP every shift for 14 days, start date 12/8/21;
- Staff recorded readings of
*12/8/21 on the night shift of 156/117;
*12/10/21 on the day shift 184/92; no BP recorded on the evening shift;
*12/12/21 on the day shift 170/80;
*12/16/21 on the day shift 152/100.
Review of the interdisciplinary progress notes between 12/8/21 and 12/16/21 showed staff did not document they notified the physician of any abnormal BP results.
During an interview on 12/22/21, at 4:00 P.M., Licensed Practical Nurse (LPN) A said the resident did have an order to take his/her blood pressure. He/she could not remember if the order had parameters to call the physician, but he/she would go by what is considered normal blood pressures.
During an interview on 12/22/21 at 4:22 P.M., the Director of Nursing and Administrator said if the physician gives an order for contacting him/her with abnormal blood pressures, staff should clarify the orders and ask for specific parameters because this can depend on what the resident's baseline is.
2. Review of Resident #58's admission MDS, dated [DATE], showed:
- A BIMS of 8, indicating moderate cognitive impairment;
- Totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene;
- Diagnoses included stroke, high blood pressure, anxiety disorder, encephalopathy (damage or disease that affects the brain);
- Did not have oxygen therapy during or prior to admission.
Review of the POS, printed on 12/16/21, showed:
- Oxygen at 2 liters per minute (lpm) via nasal cannula (nc) PRN to keep oxygen saturation (O2 sats) above 90%;
- Order start date 12/10/21.
Review of the resident's current care plan, printed on 12/16/21, showed the resident had pneumonia. Interventions included:
- Auscultate (examine a patient by listening to sounds from the heart, lungs, or other organs, typically using a stethoscope) lung sounds; listen for crackles and diminished breathe sounds due to atelectasis (in aspiration pneumonia rhonchi and wheezing are present);
- Elevate the head of bed for comfort and lung expansion;
- Give medications as ordered;
- Monitor vital signs (VS) per re-admit protocol and as needed (PRN); notify physician of significant abnormalities; temperature every shift until completion of antibiotic;
- The plan did not address the use of oxygen.
Review of the December TAR showed:
- Change O2 tubing, humidifier bottle, and plastic holding bag for O2 tubing as needed; change weekly on Saturday night when in use; start date 12/10/21;
- No order for O2;
- No order to check the O2 sats to ensure they stay above 90%.
Review of the electronic medical record (EMR) on 12/21/21 of the resident's vital signs showed staff documented they checked the resident's O2 sats on:
- 12/8/21 at 7:40 P.M. 98.0 % on Room Air
- 12/11/21 at 5:07 A.M. 94.0 % on Room Air
- 12/12/21 at 4:04 P.M. 96.0 % Room Air
- 12/15/21 at 11:11 A.M., 97.0 % on Room Air
- 12/20/21 at 8:52 A.M. 94.0 % on Room Air.
During an interview on 12/22/21 at 4:58 P.M., LPN A said he/she checked the resident's O2 sats daily to ensure they are above 90% with the COVID assessment. He/She usually does it every morning. It is charted in the EMR.
During an interview on 12/22/21 at 4:22 P.M. the DON and administrator said staff should follow physician's orders. If they have an order to titrate O2 to keep above 90%, staff should be documenting they have checked this with the vital signs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement an effective discharge plan for one of 24 sampled residents (Resident #42) when he/she expressed the desire to move t...
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Based on interview and record review, the facility failed to develop and implement an effective discharge plan for one of 24 sampled residents (Resident #42) when he/she expressed the desire to move to a different long term care facility. The facility census was 104 at the time of the survey.
Review of the facility's Resident Handbook, revised 2018, showed:
- Statement of Resident Rights: Right to Self-Determination:
*Choice of activities, schedules, health care and providers;
*Reasonable accommodations of needs and preferences;
*The right to be adequately informed of your medical condition and proposed treatment, unless otherwise indicated by your physician, and to participate in planning of all medical treatment, including the right to refuse medication and treatment, unless otherwise indicated by your physician, and to know the probable consequences of such actions.
The facility did not provide a discharge planning policy.
Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/11/21, showed:
- A Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment;
- Independent with all activities of daily living (ADLs);
- Diagnoses included non-pressure chronic ulcer, orthopedic aftercare-surgical amputation, absence of right toe, hydronephrosis with renal/ureteral calculous obstruction (a condition characterized by excess fluid in a kidney due to a backup of urine), acute osteomyelitis (inflammation of bone caused by infection, generally in the legs, arm, or spine) of the right ankle/foot, body mass index of 40.0 to 44.9, and low back pain. The resident had no mental disabilities or intellectual diagnoses.
- The resident expected to remain in the facility; no active plan to discharge to the community; the resident did not wish to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community.
Review of the resident's demographics admission record, printed on 12/16/21, showed the facility listed the resident as his/her own responsible party.
Review of the resident's care plan showed an undated focus area which stated the resident is independent for meeting emotional, intellectual, physical and social needs.
Review of the interdisciplinary progress notes dated 10/7/21 at 1:52 P.M., showed the former Social Worker wrote the resident is doing well since admitting from another facility. The resident is alert and oriented, able to communicate needs and concerns to others. The resident was admitted to the facility with a diagnosis of a foot ulcer. The resident does not have any family mentioned in assessment. The resident uses a wheelchair to ambulate through facility. The resident is his/her own responsible party. The resident to remain in a facility setting long term.
During an interview on 12/13/21 at 4:30 P.M., the resident said he/she had asked the Marketing Director, who was acting as social services, to send his/her medical information to another facility in the area because he/she did not wish to live at the facility any longer. The other facility had a Medicaid bed available for him/her, but had never received any information regarding the resident so they gave the bed to someone else. When the resident tried to talk to the Marketing Director about this, he would repeatedly say I got you; I got you. The resident requested that the Marketing Director show him/her what information he sent to the other facility, but the Marketing Director said he could not because it had doctor stuff in it and the resident would not understand it. This made the resident feel belittled and not listened to. He/she does not believe that the Marketing Director sent any of the paperwork to the other facility. The resident moved to this facility from a sister facility after he/she had COVID-19 and had every intention of staying until he/she could care for him/herself again. He/she has a wound on his/her foot and has had several surgeries on it. He/she was homeless and living in his/her car prior to going into the hospital with the wound on his/her foot. He/she wants to someday return to the community, but knows he/she cannot until the wound is healed. The only thing that has kept him/her at the facility is the physical therapy department. He/she wants to move to another facility, because he/she does not feel they are meeting his/her needs.
During an interview on 12/20/21 at 4:10 P.M., the Marketing Director said he sent the referral to the facility the resident requested and actually sent it twice. He did not keep a copy of what he sent. He sent it from the fax machine upstairs. He does not have a transmittal to say that they received the information. He did not call the facility to be sure they received it. He only sent the face sheet and the medication list. He has not documented anywhere to show he did send it. He did not remember the resident asking to see the information he sent.
Review of the resident's interdisciplinary progress notes showed no notes regarding the resident's desire to move to a different facility.
During an interview on 12/22/21, at 4:00 P.M., the Director of Nursing and Administrator said the interdisciplinary team (IDT) is who discusses discharge planning with residents. They discuss discharge planning during the care plan meeting upon admission. During other care plan meetings they discuss residents' desire to discharge and therapy will review the plan with the resident and the family. Social services is responsible for sending paperwork to another facility, but they do not have a social worker currently. The administrator and marketing director/admissions coordinator have been doing this. They should send the resident's face sheet, physician's orders, any progress notes, and should document this in the resident's record. They expected that if a resident requested it, the facility should send the appropriate paperwork to honor the resident's request, and document they sent it and who they sent it to. Staff should help facilitate the discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions for two residents (Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions for two residents (Resident #81 and Resident #66) who displayed physically aggressive behaviors. The facility census was 89.
Review of the undated facility policy for Dementia Care showed:
-It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being.
-Definition: Dementia is a general term to describe a group of symptoms related to loss of memory, judgement, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptomology and rates of progression.
-The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible;
-The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia and dementia-like illnesses;
-Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's wellbeing;
-The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary;
-Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker).
1. Review of Resident #81's care plan for potential for a behavior problem related to agitation/delirium dated 12/31/21 showed:
-Focus: potential for a behavior problem related to agitation and delirium, wanders in his/her wheelchair;
-Goal: will have no aggressive behaviors through review;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; anticipate and meet the resident's needs; explain all procedures to the resident before starting; if reasonable, discuss the resident's behaviors. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.
Review of the quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 2/12/22 showed:
-Unable to answer questions, unaware of the date, time and person;
-No mood issues and no behaviors;
-Extensive assistance of two staff for Activities of Daily Living (ADL's);
-Five days of antipsychotic usage (a mediation used to control behaviors and mood);
-Diagnoses of dementia, aphasia (inability to speak), manic depression (Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions).
Review of the nurse's notes dated 1/26/22 at 12:52 P.M. showed:
-Resident in the dining room, slapped another resident in the face. Resident sent to local hospital.
Review of the nurse's notes dated 1/26/22 at 7:24 P.M. showed:
-Resident returned from local hospital with no new orders. Continue to monitor.
Review of the care plan for behaviors dated 12/31/21 showed no changes or additional approaches related to behavior after the 1/26/22 altercation.
Review of the nurse's notes dated 1/29/22 at 8:43 A.M. showed:
-At approximately 5:50 A.M., the resident was seen pushing another resident to the floor. This resident was removed from the dining room and sent to a local hospital.
Review of the nurse's notes dated 1/29/22 at 11:30 P.M. showed:
-The resident returned from the local hospital at 12:30 P.M. with no new orders
Review of the care plan for behaviors dated 12/31/21 showed no changes or additional approaches related to behavior after the 1/29/22 incident.
Review of the nurse's notes dated 1/31/22 at 5:27 P.M. showed:
-The resident required re-direction following inappropriate contact with staff. He/she made contact with the buttocks of a female staff member. The resident was educated.
Review of the nurse's notes dated 2/1/22 at 7:03 A.M. showed:
-The resident has been seeking out female peers to sexually molest. Nurse has had to keep him/her in the line of sight at all times since 5:00 A.M. The resident had at least four near misses with four different residents. Staff was able to intervene quickly. Interim administrator notified and he/she came to the unit to address the resident's behaviors.
Review of the nurse's note dated 2/1/22 at 8:59 A.M. showed:
-The resident was found lying in bed with a female resident with his/her pants down. The resident was trying to pull the female resident's pants down. The resident was assisted back to his/her room. A female resident entered the resident's room, the resident became aggressive toward him/her as well. The resident sent to the local hospital for evaluation.
Review of the nurses' note dated 2/1/22 at 12:54 P.M. showed:
-Local hospital called to report the resident will be admitted to a psychiatric hospital.
Review of the nurse notes dated 2/11/22 at 2:43 P.M. showed:
-The resident was readmitted to the facility from psychiatric hospital.
Review of the care plan for behaviors dated 12/31/21 showed no new approaches to address the sexually inappropriate behaviors toward residents and staff, or any new interventions from the recent psychiatric hospital admission.
Review of the nurses notes dated 2/13/22 at 1:22 P.M. showed:
-The resident was showing aggressive and inappropriate behavior toward nurses, Certified Nurse Aides (CNA's) and other residents and would not stop when asked to. Staff had to physically remove the resident's hands from touching inappropriately. The resident also slapped another resident in the face twice. The resident was sent to a local hospital for evaluation.
Review of the care plan for behaviors dated 12/31/21 showed no new interventions to address the inappropriate behaviors of 2/13/22, the physical aggression towards another resident, or the recent hospitalization.
Review of the social services note dated 2/24/22 at 8:57 A.M. showed:
-Social Services communicated with the resident's guardian. The resident's guardian has expressed a need to have the resident moved to a behavior facility. Referrals have been sent.
Review of the nurse's note dated 2/25/22 at 7:58 P.M. showed:
-The resident has been doing sexual things again. He/she tried to grab another's back side this evening. He/she has had several behaviors taking briefs, trying to get in a cart, exit seeking for hours. He/she then started spitting on the floor in the hallway. He/she was then directed to his/her room by staff and told to stay in there.
Review of the nurse's dated 2/26/22 and 2/27/22 showed:
-9:40 A.M. - Upon arrival this nurse was informed the resident had been having behaviors. As directed by the Assistant Director of Nursing (ADON) this nurse placed a call to the guardian. Approval to send the resident to the hospital. Resident left the facility at 9:34 P.M. for evaluation;
-10:28 A.M. - Nurse at the hospital called for report as to why the resident was at the hospital;
-12:13 A.M. - The resident returned to the facility.
Review of the nurse's notes dated 2/28/22 at 2:46 P.M. showed:
-The resident sent to a hospital for evaluation related to sexual aggression, grabbing buttocks and private areas of other residents and staff. The resident also pulled the fire alarm and was exit seeking all shift.
Review of the nurse's notes dated 3/1/22 showed:
- At 12:52 A.M. spoke with the hospital's professional team with recommendations for the resident to return to the facility and see the facility's psychiatrist for a mediation adjustment;
-3:24 A.M. the resident is transferred back to the facility.
-9:23 A.M. the resident continues to grab at staff's buttocks and is going in other resident's rooms;
-6:27 P.M. the resident was into everything this evening. Attempted to get into nursing station, in stuff on the cart. Kept going to the doors. Standing up from the wheelchair and having to be told to sit down as he/she was unstable on his/her feet.
Review of the care plan for behaviors dated 12/31/21 showed no new interventions for the sexually aggressive behaviors, nor of the resident being sent to a psychiatric hospital.
Review of the nurse's notes dated 3/5/22 showed:
- 2:18 P.M. the resident came into the dining room and propelled next to another resident. He/she said something to this resident. The resident said something to him/her, then he/she slapped this resident with an open hand on the cheek two times. This writer immediately separated the two residents and took this resident to his/her room because he/she stated he/she was tired. The resident was sent to a local hospital for evaluation.
-11:00 P.M. the resident returned from the hospital with no new orders.
Review of the social services note dated 3/7/22 at 9:07 A.M. showed:
-The IDT team met to discuss the resident's recent behaviors. Resident can display inappropriate touch of other people. He/she has been sent out for psychiatric hospitalization on 1/21/22, 1/29/22, 2/1/22, 2/27/22 and 2/28/22. Resident currently takes Risperdal (used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, irritability associated with autistic disorder) for bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). Quetiapine (Seroquel, an antipsychotic medicine that is used to treat schizophrenia (a serious mental disorder in which people interpret reality abnormally.) for unspecified dementia, bipolar disorder and mood.
During the observation period of 3/21/22 through 3/23/22 showed the resident was on one on one observation by one staff member.
Review of the behavior care plan dated 12/31/21 showed no changes or addition of interventions for the sexually aggressive behaviors, the admissions to the psychiatric hospitals or the medication used or the one on one observation.
Review of the nurse's notes dated 3/8/22 through 3/19/22 showed documentation of the resident's continued sexually inappropriate behaviors. Review of the care plan showed no documentation for any interventions in place for staff to utilize for the sexually inappropriate behaviors.
During an interview on 3/23/22 at 2:00 P.M. the Corporate Nurse and Director of Operations said:
-They were aware of the resident's physically aggressive behaviors and were attempting to find appropriate placement for the resident. They have sent out referrals to several facilities, but at this point no one will take the resident.
2. Review of Resident #66's quarterly MDS dated [DATE] showed the following:
- Long-term and short-term memory problems
- Had wandering behaviors
- Used a wheelchair for mobility
- Diagnoses included Alzheimer's disease, Dementia, Parkinson's disease, anxiety, depression, and schizophrenia.
Review of the resident's care plan dated 10/22/21 and revised on 2/17/22 included the following:
- The resident has been physically aggressive related to dementia;
- Aggressive towards peers at times;
- 12/19/21 Attempts to take baby doll from a peer, becomes agitated, hitting at resident;
- 12/22/21 Making stabbing motion with his/her fork in the dining room, tried to bite staff;
- 1/3/22 Agitated with peer, trying to lunge at him/her;
- 1/19/22 Hit a peer;
- 3/17/22 Physically aggressive toward a female peer;
- The resident will demonstrate effective coping skills.
- The resident will not harm self or others.
- When the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away, and approach later.
- The facility did not update the care plan since 1/20/22 when they put the resident on 15 minutes checks.
3. During an interview on 3/24/22 at 2:00 P.M. the interim Director of Nursing said:
-Staff should receive training for residents with behaviors through in-servicing from the management staff or training from outside educators on how to address the resident's behaviors.
-Staff should identify the resident's behavior, put interventions in place to address the behavior, update the care plan then educate the staff on the interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure monitor two of 24 sampled residents' (Residents #42 and #88)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure monitor two of 24 sampled residents' (Residents #42 and #88) medications for unnecessary medications and did not have a plan in place to ensure as needed (PRN) opioids were discontinued after 14 days or the residents' assessed for the need for continued use. The facility census was 104.
The facility did not provide a policy addressing their medication regimen review (MRR), consultant pharmacist's role, and discontinuation of PRN opioids.
1. Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/11/21, showed:
- A Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment;
- Independent with all activities of daily living (ADLs);
- Diagnoses included non-pressure chronic ulcer, orthopedic aftercare-surgical amputation, absence of right toe, hydronephrosis with renal/ureteral calculous obstruction (a condition characterized by excess fluid in a kidney due to a backup of urine), acute osteomyelitis (inflammation of bone caused by infection, generally in the legs, arm, or spine) of the right ankle/foot, body mass index of 40.0 to 44.9 (morbid obesity), and low back pain;
- Has been on scheduled pain medication regimen in the last five days; received PRN pain medications;
- Frequently experiencing pain; does not affect sleep or limit day-to-day activities; highest pain intensity on a 0 to 10 scale = 05.
- The resident is at risk for developing pressure ulcers; no unhealed pressure ulcers;
- Infection of the foot (examples include cellulitis, purulent drainage); diabetic foot ulcers;
- Open lesions other than ulcers, rashes, cuts (examples cancer lesion); moisture associated skin damage (MASD);
- Received an antidepressant six of the last seven days; opioids two of the last seven days.
Review of the resident's undated care plan showed:
- The resident uses antidepressant medication related to depression and pain. Interventions included:
-10/31/21 physician ordered Trazadone (used to treat depression as well as a sleep aid) 50 milligrams (mg) at HS (hour of sleep) for insomnia;
-Administer antidepressant medication as ordered by physician; monitor/document side effects and effectiveness every shift;
-Education resident about risks, benefits, and the side effects and/or toxic symptoms of antidepressant drugs being given;
- The resident has acute/chronic pain related to depression, diabetic neuropathy and a wound. Interventions included:
-Anticipate the resident's needs for pain relief and respond immediately to any complaints of pain;
-Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function
-Monitor/document for probable cause of each pain episode. Remove/limit causes where possible;
-Monitor/document for side effects of pain medications. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. Report to the physician;
-Monitor/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing);
-Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss;
-Monitor/record/report to nurse resident's complaints of pain or requests for pain treatment
-Notify physician if interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain.
Review of the resident's December 2021 physician's order sheet (POS) showed:
- Assess pain every shift;
- Hydrocodone-acetaminophen tablet 5/325 mg, give one tablet every four hours PRN for pain; not to exceed 3 grams (GM) acetaminophen in all medications in 24 hours; start date 10/24/21.
Review of the resident's October 2021 treatment administration record (TAR) showed:
- Hydrocodone-acetaminophen tablet 5/325 mg, give one tablet every four hours PRN for pain; not to exceed 3 grams (GM) acetaminophen in all medications in 24 hours; start date 10/4/21.
- Staff documented they administered the medication 25 times.
Review of the resident's November 2021 treatment administration record (TAR) showed:
- Hydrocodone-acetaminophen tablet 5/325 mg, give one tablet every four hours PRN for pain; not to exceed 3 grams (GM) acetaminophen in all medications in 24 hours; start date 10/4/21.
- Staff documented they administered the medication 11 times.
Review of the resident's December 2021 treatment administration record (TAR) showed:
- Hydrocodone-acetaminophen tablet 5/325 mg, give one tablet every four hours PRN for pain; not to exceed 3 grams (GM) acetaminophen in all medications in 24 hours; start date 10/4/21.
- Staff documented they administered the medication 3 times as of 12/16/21.
Review showed no medication regimen reviews for the resident to indicate if the resident had any unnecessary medications, nor any reviews of the resident's extended use of pain medications.
2. Review of Resident #88's admission MDS, dated [DATE] showed:
- A BIMS of 15 which indicated no cognitive impairment;
- Feeling down, depressed or hopeless at least one day during the assessment period; no behaviors noted;
- Independent with all ADLs with the exception of needing limited staff assistance for dressing and supervision with toilet use; did not walk in corridor or room;
- Diagnoses included: stroke; psychoactive substance abuse, alcohol related disorder, palliative care, anxiety, depression, high blood pressure, chronic viral hepatitis C, congestive heart failure, Stage 3 chronic kidney disease, right side paralysis;
- Has been on a scheduled pain medication in the last five days, has not taken any PRN (as needed) pain medications; not experiencing any pain at the time of the assessment;
- Has a chronic disease or condition that may result in a life expectancy of less than six months;
- Received antianxiety medications four of the past seven days; antidepressants seven of the past seven days; received opioid (highly addictive narcotic pain medications) medications seven of the past seven days;
- Hospice care.
Review of the resident's quarterly MDS, dated [DATE], showed:
- Received PRN pain medications; did not receive any non-medication interventions for pain;
- Frequently experienced pain; pain has made it hard to sleep at night; pain has limited day-to-day activities; rated his/her pain at a 10;
- Received antipsychotic medications two of the last seven days; antianxiety medications seven of the last seven days; antidepressants seven of the last seven days; opioid medications seven of the last seven days;
- Hospice care.
Review of the resident's undated care plan showed:
- The resident has chronic pain related to stroke with right side paralysis; Refuses pain patch at times. Interventions included:
-11/6/2021: screaming that his/her nerve pain in his/her feet are worse; physician/hospice called and ordered dosage changes to his/her Neurontin (used to treat nerve pain)/Baclofen (treat pain and certain types of spasticity). Few hours later was screaming again about the pain. Hospice notified and came out to exam him/her; received orders for medication changes; see medication administration record (MAR).
-Administer analgesia as per orders.
-Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.
-Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.
-Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function.
-Identify, record and treat the resident's existing conditions which may increase pain and or discomfort: paresthesia related to stroke;
-Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea and vomiting; dizziness and falls. Report occurrences to the physician;
-Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss;
-Monitor/record/report to Nurse if resident complains of pain or requests for pain treatment;
-Notify Hospice and place on Dentist list;
-Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain;
-Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care;
-Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complaints of pain or discomfort;
-The resident is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain.
Review of the resident's December 2021 MAR/TAR showed:
- Dilaudid (a highly addictive narcotic used to treat moderate to severe pain or a level of 4 to 10 on the pain scale) tablet 2 milligrams (mg), give one table by mouth as needed (PRN) for pain TID (three times a day)/ PRN; start date 11/26/21;
- Staff documented they administered the Dilaudid 51 times between 12/1/21 and 12/22/21.
Review showed no medication regimen reviews for the resident to indicate if the resident had any unnecessary medications, nor any reviews of the resident's extended use of pain medications.
3. During an interview on 12/22/21 at 4:30 P.M. the Director of Nursing and the Corporate Nurse B said:
-The pharmacist will provide his/her recommendations to the DON so the DON can contact the physician with the recommendations;
-She cannot find any pharmacist recommendations;
-The recommendations should be kept in the DON's office in a binder;
-Once the pharmacist makes the recommendations, they are sent to the resident's physician for review;
-Once the physician returns the recommendations, they are scanned in the resident's electronic medical record and the nurses carries out any orders that has been given;
-There is no pharmacist recommendation in the office and she cannot find any pharmacist recommendations.
-Residents with orders for PRN narcotics should have stop dates at 14 days and have the order renewed by their physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure two of 24 sampled residents (Residents #69 and #71) receive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure two of 24 sampled residents (Residents #69 and #71) received gradual dose reductions (GDR) for psychotropic drugs (drugs that affect a person's mental state) and failed to ensure as needed (PRN) psychotropic drugs were limited to 14 days unless the resident's physician believed it was appropriate for PRN use and documented their rationale or, in the case of anti-psychotic drugs (a medication that is believed to be effective in the treatment of psychosis), can be renewed only after being evaluated by the attending physician. The facility census was 104.
The facility did not provide a policy regarding GDRs or PRN use of psychotropic medications.
1. Review of Resident #69's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed:
- A Brief Interview for Mental Status (BIMS) score of 10, which indicated mild cognitive impairment;
- Extensive staff assistance for bed mobility, moving on and off the nursing unit, dressing, toilet use and personal hygiene; totally dependent on staff for transferring from one surface to another;
- Diagnoses included stroke, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), coronary artery disease (damage or disease in the heart's major blood vessels; the usual cause is the buildup of plaque which causes coronary arteries to narrow, limiting blood flow to the heart), high blood pressure, dementia, seizures, depression, anorexia, and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage).
- Has had pain the last five days, but did not indicate staff administered any pain medications, either as needed (PRN) or scheduled or any non-medication interventions for the resident's pain;
- Does have a condition or chronic disease that may result in a life expectancy of less than six months;
- Received antipsychotic, antidepressants and anticoagulant medications seven of the previous seven days; received antipsychotics on a routine basis only;
- Hospice care while a resident of the facility.
Review of the resident's December 2021 physician's order sheet (POS) showed:
- Order date 11/13/21: Lorazepam (used to treat anxiety, belongs to a class of drugs known as benzodiazepines, a class of drugs primarily used for treating anxiety, tablet 0.5 milligrams (mg), give 1 tablet by mouth every 12 hours PRN for anxiety;
- Order date 2/24/21, mirtazapine (an antidepressant) tablet, 30 mg, give 1 tablet orally at bedtime related to adjustment disorder with depressed mood;
- Order date 1/1/21, Trintellix (an antidepressant) tablet 20 mg, give 1 tablet orally one time a day related to adjustment disorder with depressed mood;
- Order date 1/24/21, Rexulti (atypical antipsychotic or second generation psychotic) tablet 1 mg, give 1 tablet orally one time a day related to adjustment disorder with depressed mood.
Review of the resident's interdisciplinary progress notes (IDP) showed:
- 7/28/21 Pharmacy Note: Medication Regimen Review (MRR) completed, please see report for recommendation;
- 9/24/21 Pharmacy Note: MRR completed, please see report for recommendation.
- No other progress notes to indicate what those two recommendations where.
- No notes to indicate they had attempted a GDR of the resident's antidepressants or a note from the physician stating a GDR would be contraindicated.
Review of the resident's treatment administration record (TAR) showed:
- Order date 11/13/21: Lorazepam tablet 0.5 milligrams (mg), give 1 tablet by mouth every 12 hours PRN for anxiety;
- Staff did not document they administered the medication between 12/1/21 and 12/16/21.
The facility could not provide any pharmacy recommendation other than a printout dated 12/16/21, to show whose records the consultant pharmacist had reviewed. They could not provide an individual MRR for Resident #69.
2. Review of Resident #71's quarterly MDS, dated [DATE], showed:
- A BIMS of 15, indicating no cognitive impairment;
- No symptoms of depression or mood disorders;
- No behaviors present;
- Extensive assistance from staff for bed mobility, dressing, and personal hygiene; total dependence from staff for toilet use; resident did not transfer out of bed and did not move on or off the nursing unit;
- Diagnoses included manic depression (bipolar disorder);
- Received an antidepressant seven of the last seven days.
Review of the resident's December 2021 medication administration record (MAR) showed:
- Order date 2/1/21; Prozac (used to treat depression, obsessive-compulsive disorder, bulimia nervosa, and panic disorder) 40 mg, give one capsule by mouth one time a day for depression;
- Order date 2/1/21; Wellbutrin XL (used to treat depression) tablet extended release 24 hour 300 mg, give one tablet by mouth one time a day for depression.
Review of the IDN showed:
- 11/22/21 Pharmacy Note: MRR completed; no recommendations at this time;
- 8/23/21 Pharmacy note: MRR completed; please see report for recommendations;
- No other pharmacy notes were found;
- No evidence the facility attempted a GRD for the resident's antidepressants;
- No physician's note to indicate a rationale to not complete a GRD for the resident's antidepressants.
3. During an interview on 12/22/21 at 4:30 P.M. the Director of Nursing and the Corporate Nurse B said:
-The pharmacist will provide his/her recommendations to the DON so he/she can contact the physician with the recommendations;
-She cannot find any pharmacist recommendations;
-The recommendations should be kept in the DON's office in a binder;
-Once the pharmacist makes the recommendations, they are sent to the resident's physician for review;
-Once the physician returns the recommendations, they are scanned in the resident's electronic medical record and the nurses carry out any orders that have been given;
-There are no pharmacist recommendations in the office and she cannot find any pharmacist recommendations;
- Residents with orders for PRN narcotics should have stop dates at 14 days and have the order renewed by their physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure they collaborated with hospice to ensure hospice staff and facility staff knew who would be responsible to provide specific services...
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Based on record review and interview, the facility failed to ensure they collaborated with hospice to ensure hospice staff and facility staff knew who would be responsible to provide specific services for one of 24 sampled residents (Resident #69). The facility census was 104.
1. Review of the facility's Hospice-Skilled Nursing Facility (SNF) contract, approved 10/1/19, showed:
- Nursing Facility Plan of Care (NFPOC) shall mean a written care plan established, maintained, reviewed and modified, if necessary, by the facility's interdisciplinary team which includes the attending physician, a registered professional nurse with responsibility for the hospice patient, and other appropriate staff of the facility with the participation of hospice, the hospice patient and patient's family to the extent practicable. The facility's plan of care shall be consistent with the hospice plan of care (HPOC) for the hospice patient;
- Responsibilities of hospice included the hospice plan of care: the hospice interdisciplinary group shall prepare an individualized written HPOC for each hospice patient in the facility. The HPOC shall specify the hospice care and services necessary to meet the needs of the hospice patient and his/her family as identified in the initial, comprehensive and updated assessments as such needs relate to the terminal illness and related conditions, and shall include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:
a. interventions to manage pain and symptoms
b. the scope and frequency of services necessary to meet the specific patient and family needs
c. measurable outcomes anticipated from implementing and coordinating the HPOC
d. drugs, treatment, medical supplies, and appliances necessary to meet the needs of the hospice patient
e. clinical record documentation of the patient's or representative's level of understanding involvement, and agreement with the HPOC.
- All hospice care shall be provided in accordance with the HPOC. The HPOC shall reflect the participation of hospice, the facility and the hospice patient and his/her family to the extent possible. In addition, the HPOC shall specifically identify which provider is responsible for performing the care and services included in the HPOC.
- Hospice services shall include, without limitation, provided medical direction and management of the patient; nursing services; counseling including spiritual, dietary, and bereavement counseling; social work services; provisions of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
Review of Resident #69's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed:
- A Brief Interview for Mental Status (BIMS) score of 10, which indicated mild cognitive impairment;
- Extensive staff assistance for bed mobility, moving on and off the nursing unit, dressing, toilet use and personal hygiene; totally dependent on staff for transferring from one surface to another;
- Diagnoses included stroke, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), coronary artery disease (damage or disease in the heart's major blood vessels; the usual cause is the buildup of plaque which causes coronary arteries to narrow, limiting blood flow to the heart), high blood pressure, dementia, seizures, depression, anorexia, and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage).
- Has had pain the last five days, but did not indicate staff administered any pain medications, either as needed (PRN) or scheduled or any non-medication interventions for the resident's pain;
- Does have a condition or chronic disease that may result in a life expectancy of less than six months;
- Received antipsychotic, antidepressant and anticoagulant medications seven of the previous seven days; received antipsychotics on a routine basis only;
- Hospice care while a resident of the facility.
Review of the resident's current FPOC, printed on 12/16/21, showed:
- The resident has a Do Not Resuscitate (DNR) code status; notify hospice of his/her death;
- Has an activities of daily living (ADL) self-care performance deficit; he/she is totally dependent on one to two staff to provide bathing/showers twice weekly and PRN; only wants hospice to give his/her showers.
- Has potential for a nutritional problem; hospice care related to stroke;
- The resident is on hospice services related to stroke; adjust provisions of ADLs to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate; assess coping strategies and respect his/her wishes; consult with physician and social services to have hospice care for him/her in the facility; encourage to express feelings, listen with non-judgmental acceptance, compassion; encourage support system of family and friends; hospice is supplying the following: briefs. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near; observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain; review his/her living will and ensure it is followed; work cooperatively with hospice team to ensure his/her spiritual, emotional, intellectual, physical and social needs are met; work with nursing staff to provide maximum comfort for him/her.
- The FPOC had no dates of when any of the focus areas and interventions were implemented.
Review of the resident's physician's order sheet (POS), printed on 12/16/21, showed:
- Resident is a patient of hospice, order date 3/22/21, start date 3/28/21;
- Lorazepam (used to treat anxiety) 0.5 milligrams (mg), give one tablet by mouth every 12 hours PRN for anxiety, start today 11/13/21.
Review of the resident's hospice binder, located at the nurses' station, showed a Hospice/Long-Term Care Coordinated Task Plan of Care, dated 3/16/21. The plan did not include any information on what services facility staff would provide to the resident and what hospice staff would provide. The only information it included was a Bed/Broda chair (a special type of reclining wheelchair) and incontinence supplies. The binder did not include any other information except hospice staff sign-in sheets.
Review of the resident's medical record on 12/16/21 showed the only documentation in the facility's electronic medical records (EMR) regarding the resident's hospice services was dated 1/20/20.
During an interview on 12/22/21 at 3:30 P.M., Licensed Practical Nurse (LPN) A said the only information he/she had from hospice was what was located in the binders. He/she did not know what services the resident's hospice provided for him/her. They do come and visit him/her and their staff provide showers when they are in the building, but he/she believed facility staff provided showers as well. They have so many agency staff who work on this unit, it is probably a good thing hospice provides ADL care for him/her or he/she might not get any.
During an interview on 12/22/21 at 4:22 P.M., the director of nursing said hospice care plans should be coordinated with the hospice provider and accessible to nursing staff. She did not know why they did not have an up to date HPOC for the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to provide appropriate notices within 48 to 72 hours of when residents' skilled nursing services were discontinued, which affected three of 24...
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Based on record review and interview, the facility failed to provide appropriate notices within 48 to 72 hours of when residents' skilled nursing services were discontinued, which affected three of 24 residents. (Residents #12, #30 and #204) The facility's census was 104.
Review of the facility's admission packet showed:
- Appendix 5 Items and Services Included in the Daily Rate: Medicare Part A: If you are eligible to receive benefits under the Medicare Part A program, the following services will be covered at the daily rate paid to use by such program, subject to any physician orders, medical necessity criteria, or prior authorization requirements, imposed by Medicare. Please note that certain other items and services (examples include: physician fees, prescription medications, etc.) may be covered by other parts of the Medicare program. If you have any questions about such coverage, please contact our business office. The list included:
*Room;
*Nursing, dietary, activities, bathing, linen, housekeeping and maintenance, and medically-related social services;
*Routine over the counter medications and supplies ordered by your attending physician;
*Basic personal laundry
*Routine personal hygiene items and services;
*Equipment necessary to the operation of our facility, and necessary for proper medical, nursing, respiratory and rehabilitative care;
- Appendix 6 Items and Services not Included in the Daily Rate: Medicare Part A: If you are eligible to receive benefits under the Medicare Part A program, the following general categories of services are not included in the daily rate paid to us by such program, and will be your responsibility. This list is subject to periodic update upon advance notice. Current Charges for these services are available upon your request and are also subject to change. Please note that certain items and services may be covered by other parts of the Medicare Program. If you have any questions about such coverage, please contact our Business Office. This list included:
*Beautician and barber services as requested by you;
* Gift purchased on behalf of a resident;
*Certain special care services, such as private duty nurse services;
*Non-routine personal care items not prescribed by a physician;
*Personal clothing and dry cleaning;
*Personal comfort items, including smoking materials, notions, novelties, and confections (candies);
*Personal reading materials, and subscriptions;
*Private room, except when therapeutically required;
*Social events and entertainment offered outside the scope of the activities program;
*Specially prepared or alternative food requests;
* Telephone and television/radio for personal use
*Flowers and plants;
- The admission packet did not discuss when the facility would notify residents about changes to their payer source or when they would be discharged from skilled nursing services.
The facility did not provide a specific policy regarding notifications of residents with changes to their payer source.
1. Review of Resident #30's Notice of Medicare Non-Coverage (NOMNC, a notice given to the resident and/or their responsible party prior to a resident who has skilled benefit days remaining and is being discharged from Part A services whether they are leaving the facility immediately following the last covered skilled day or remaining in the facility) showed:
- Services will end on 7/3/21;
- The resident signed the form, but did not date it;
- Staff dated the form 6/30/21.
Review of the resident's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN a notice provided to the resident and/or their responsible party when the resident has skilled benefit days remaining, is being discharged from Part A services and will continue living in the facility) showed:
- Services will end on 7/3/21;
- The resident signed the form, but did not date it;
- Staff dated the form 6/30/21.
2. Review of Resident #204's medical record showed no NOMNC.
Review of the resident's interdisciplinary progress notes showed:
- 7/7/21 12:25 P.M.: Discharge Summary Note Text: Resident discharged to home today, accompanied by sister. All medications and medication list were sent home with patient. Discharge instructions were provided, both verbalized understanding. Resident left facility at around 10:00 A.M. via private vehicle.
- The record did not include any notes the resident chose to go home prior to being discharged from skilled nursing services.
During an interview on 12/20/21, at 3:30 P.M. the administrator said the resident did not receive the letters as he/she chose to leave with his/her sister. She did not see any documentation other than the progress notes to indicate this was not a planned discharge. Staff should document when a resident chooses to leave the facility before therapy discharges them.
3. Review of Resident #12's medical records showed no NOMNC and no SNFABN, and no evidence of a 5-day letter being provided to the resident upon discharge from therapy.
During an interview on 12/20/21 at 3:30 P.M., the Administrator said she did not have any letters for this resident. Therapy issued a 5-day notice. She would see if she could find the 5-day notice. Therapy does not issue the NOMNC or the SNFABN.
The facility did not provide the notice to the survey team prior to exit.
4. During an interview on 12/22/21 at 4:20 P.M., the Administrator said:
- Social services typically provides the NOMNC and SNFABN notices to residents or their representatives, but the Minimum Data Set (MDS) coordinator has been handling it.
- She had previously been the therapy program manager before being named the facility administrator last week and she provided Residents #12 and #204 with the five day discharge notices and she has copies of these.
- Staff dated Resident #30's form so there is no way to know if he/she received it timely.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to maintain copies of staff's criminal background checks (CBC), Family Care Safety Registry (FCSR) letters, checks of the employee disqualific...
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Based on record review and interview, the facility failed to maintain copies of staff's criminal background checks (CBC), Family Care Safety Registry (FCSR) letters, checks of the employee disqualification list (EDL) and nurse aide (NA) registry. This affected seven of seven staff members sampled. The facility census was 104.
Review of the facility's abuse, neglect, and exploitation policy, dated 11/1/21, showed:
- It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
- The facility will develop and implement written policies and procedures that:
a. Prohibit and prevent abuse, neglect, and exploitation of residents.
b. Establish policies and procedures to investigate any such allegations; and
c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention;
- The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation of the state survey agency and other officials in accordance with state law.
- Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.
1. Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants.
2. Screenings may be conducted by the facility itself, third-party agency or academic institution.
3. The facility will maintain documentation of proof that the screenings occurred.
1. Review of Certified Nurse Aide (CNA) E's personnel records showed:
- Hire date of 10/26/21;
- FCSR letter dated 12/15/21;
- EDL check dated 12/15/21;
- NA registry check dated 12/15/21.
2. Review of Certified Medication Technician (CMT) B's personnel records showed:
- Hire date of 11/18/21;
- FCSR letter dated 12/15/21;
- EDL check dated 12/15/21;
- NA registry check dated 12/15/21.
3. Review of CNA F's personnel records showed:
- Hire date of 12/2/21;
- FCSR letter dated 12/15/21;
- EDL check dated 12/15/21;
- NA registry check dated 12/15/21.
4. Review of Registered Nurse (RN) A's personnel records showed:
- Hire date of 11/4/21;
- FCSR letter dated 12/15/21;
- EDL check dated 12/15/21;
- NA registry check dated 12/15/21.
5. Review of the Occupational Therapist's personnel records showed:
- Hire date of 8/23/21;
- FCSR letter dated 12/15/21;
- EDL check dated 12/15/21;
- NA registry check dated 12/15/21.
6. Review of Licensed Practical Nurse (LPN) F's personnel records showed:
- Hire date of 10/18/21;
- FCSR letter dated 12/15/21;
- EDL check dated 12/15/21;
- NA registry check dated 12/15/21.
7. Review of the Maintenance Director's personnel records showed:
- Hire date of 11/4/21;
- FCSR letter dated 12/15/21;
- EDL check dated 12/15/21;
- NA registry check dated 12/15/21.
During an interview on 12/22/21 at 4:22 P.M., the administrator said they do not currently have a human resources person. They believe that someone sabotaged them and destroyed the personnel files. They reran all of the screenings on 12/15/2021 once they realized they did not have them.
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 provide written notice of transfer or discharge to res...
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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 written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer in writing in a language they understood. This affected three of 24 sampled residents (Residents #58, #84 and #85). The facility census was 104.
The facility did not provide a policy for notices of transfer or discharge.
1. Review of Resident #84's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/5/21 showed:
-Unable to make decisions, cognitively impaired;
-Diagnoses of hypertension, diabetes, stroke, aphasia (inability to speak), seizure disorder, anxiety and psychotic disorder (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality).
Review of the resident's electronic medical record showed:
-The resident was sent to the hospital on [DATE] for unresponsiveness in the dining room.
-There was no documentation in the medical record that a discharge letter was given to the resident or responsible party or sent with the resident to 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 12/13/21 at 9:30 A.M. Licensed Practical Nurse (LPN) D said:
-He/she sent the resident to the hospital on [DATE];
-He/she could not print any paperwork, as none of the printers the nurses had access to were working;
-He/she does not have access to any printers once the office staff leaves.
-During a week day, the MDS coordinator, will send the discharge letters;
-On 12/11/21, he/she did not send a discharge letter with the resident to the hospital.
During an interview on 12/14/21 at 11:35 A.M. Family Member (FM) A said:
-He/she is concerned about the number of times that his/her loved one has been in and out of the hospital.
-On Saturday, December 10, 2021 the resident was unresponsive in the dining room.
-The facility did call to let him/her know that they were sending the resident to the hospital.
2. Review of Resident #58's admission MDS, dated [DATE], showed:
- A Brief Interview of Mental Status (BIMS) score of eight, indicating moderate cognitive impairment;
- Total dependence on staff for activities of daily living (ADLs);
- Diagnoses included stroke, high blood pressure, urinary tract infection (UTI), anxiety, encephalopthy (damage or disease that affects the brain).
Review of the resident's discharge assessment MDS, dated [DATE], showed staff coded this as an unplanned discharge with the resident's return to the facility anticipated. Staff discharged the resident to an acute care hospital.
Review of the resident's interdisciplinary progress notes showed staff documented on 12/7/21 the resident returned from the hospital with a new tube feeding and antibiotics for pneumonia. The progress notes did not include a discharge letter to indicate when the resident was discharged to the hospital or if the staff sent a discharge letter to the resident's power of attorney or provided one to him/her when they discharged him/her to the hospital.
3. Review of Resident #85's quarterly MDS, dated [DATE], showed:
- A BIMS score of 15, indicating the resident had no cognitive impairment;
- Required extensive staff assistance with bed mobility and dressing, total dependence on staff for toilet use and transfers, did not walk in his/her room or in the corridor;
- Did not move from a seated to standing position, did not walk even with walking devices, could not turn around and face the opposite direction while walking; and did not move from one surface to another. Used an electric wheelchair from mobility;
- Diagnoses included debility, cardiorespiratory conditions, anemia, high blood pressure and diabetes.
Review of the Resident MDS Viewer, a Federal computer program where all transmitted MDS information is stored, showed staff discharged and readmitted the resident on the following dates:
- discharged [DATE]; readmitted [DATE];
- discharged [DATE]; readmitted [DATE];
- discharged [DATE].
Review of the resident's medical record on 12/19/21 showed no evidence staff provided the resident with any discharge notices when they transferred him/her out to the hospital.
4. During an interview on 12/22/21 at 4:22 P.M. the Director of Nursing and Corporate Nurse B said:
-The charge nurses are responsible for sending a discharge letter with the resident when they send a resident to the hospital;
-If the nurses do not have access to copy machine they should send the original.
-The nurses should document in the resident's medical record that the discharge letter was sent with the resident to the hospital.
CONCERN
(E)
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** Based on interview and record review, the facility failed to inform residents and their family/legal representatives of the bed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform residents and their family/legal representatives of the bed hold policy at the time of transfer/discharge to the hospital for three of 24 sampled residents (Residents #58, #84 and #85). The facility census was 104.
Review of the undated facility's policy for Temporary Leave Bed-Hold showed:
- If a resident leaves the facility on a temporary basis for medically-necessary inpatient hospitalization or therapeutic leave (visits home with family or friends), the resident or his/her legal representative may ask the Facility to hold the resident's bed open and the Facility will hold the resident's bed;
- The resident and/or his/her representative will be given a copy of the Facility bed-hold policy before the resident actually leaves for his/her temporary leave or hospitalization;
- In the case of emergency hospitalization, the bed hold policy may accompany the resident to the hospital or it will be given to the resident or his/her representative within twenty-four (24) hours of the hospitalization.
1. Review of Resident #84's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/5/21, showed:
-Unable to make decisions, cognitively impaired;
-Diagnoses of hypertension, diabetes, stroke, aphasia (inability to speak), seizure disorder, anxiety and psychotic disorder (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality).
Review of the resident's electronic medical record showed:
-The resident was sent to the hospital on [DATE] for unresponsiveness in the dining room.
-There was no documentation in the medical that the bed-hold letter was given to the resident or responsible party or sent with the resident 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 12/13/21 at 9:30 A.M. Licensed Practical Nurse (LPN) D said:
-He/she sent the resident to the hospital on [DATE];
-He/she could not print any paperwork, as none of the printers the nurses had access to were working;
-He/she did not have access to any printers once the office staff leaves.
-On 12/11/21, he/she did not send a bed-hold letter with the resident to the hospital.
During an interview on 12/14/21 at 11:35 A.M. Family Member (FM) A said:
-On Saturday, December 10, 2021 the resident was unresponsive in the dining room.
-The facility did call to let him/her know that they were sending the resident to the hospital.
-He/she did not receive a bed-hold letter
2. Review of Resident #58's admission MDS, dated [DATE], showed:
- A Brief Interview of Mental Status (BIMS) score of eight, indicating moderate cognitive impairment;
- Total dependence on staff for activities of daily living (ADLs);
- Diagnoses included stroke, high blood pressure, urinary tract infection (UTI), anxiety, encephalopthy (damage or disease that affects the brain).
Review of the resident's discharge assessment MDS, dated [DATE], showed staff coded this as an unplanned discharge with the resident's return to the facility anticipated. Staff discharged the resident to an acute care hospital.
Review of the resident's interdisciplinary progress notes showed staff documented on 12/7/21 the resident returned from the hospital with a new tube feeding and antibiotics for pneumonia. The progress notes did not indicate when the resident was discharged to the hospital or if the staff sent a copy of their bedhold policy to the resident's power of attorney or provided one to him/her when they discharged him/her to the hospital.
3. Review of Resident #85's quarterly MDS, dated [DATE], showed:
- A BIMS score of 15, indicating the resident had no cognitive impairment;
- Required extensive staff assistance with bed mobility and dressing, total dependence on staff for toilet use and transfers, did not walk in his/her room or in the corridor;
- Did not move from a seated to standing position, did not walk even with walking devices, could not turn around and face the opposite direction while walking; and did not move from one surface to another. Used an electric wheelchair from mobility;
- Diagnoses included debility, cardiorespiratory conditions, anemia, high blood pressure and diabetes.
Review of the resident's MDS Viewer, a Federal computer program where all transmitted MDS information was stored, showed staff discharged and readmitted the resident on the following dates:
- discharged [DATE]; readmitted [DATE];
- discharged [DATE]; readmitted [DATE];
- discharged [DATE].
Review of the resident's medical record on 12/19/21 showed no evidence staff provided the resident with the bedhold policy when they transferred him/her out to the hospital.
4. During an interview on 12/22/21 at 4:22 P.M., the Director of Nursing and Corporate Nurse B said:
-The charge nurses are responsible for sending the bedhold letter with the resident when they send a resident to the hospital;
-If they do not have access to a copy machine they should send the original.
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** 2. Review of Resident #43's annual MDS, dated [DATE], showed:
- A BIMS score of 3, indicating severe cognitive impairment;
- Lim...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #43's annual MDS, dated [DATE], showed:
- A BIMS score of 3, indicating severe cognitive impairment;
- Limited assistance with bed mobility, walking in his/her room, moving on and off the nursing unit, and dressing; extensive assistance with toilet use and transfers;
- Always incontinent of bladder and occasionally incontinent of bowel;
- Diagnoses included: non-traumatic brain dysfunction, dementia, depression, psychotic disorder, difficulty walking, muscle weakness, and lack of coordination;
- No falls since admission or prior to assessment.
Review of the resident's progress notes, dated 11/2/21 at 7:24 A.M., showed the following nurses' note:
- This nurse was notified by resident's roommate that the resident fell.
- When this nurse went into the room to assess, the resident was laying on his/her right side by his/her bed. The wheelchair was pushed back by the door, with wheels not locked.
- The resident stated that he/she just wanted to get back into bed.
- The resident was able to stand up with assistance by this nurse and aide with no grimacing or other signs or symptoms of discomfort.
- The resident was helped back into bed.
- Range of motion preformed on all extremities, no pain voiced and all extremities moved freely.
- Skin was clear of any bruising or injury.
- The resident stated he/she was not in any pain at this time.
- Director of Nursing (DON), physician, and family notified.
Review the resident's current undated care plan, printed on 12/21/21, showed the plan had no interventions for falls.
Observation on 12/14/21 at 9:30 A.M., showed the resident sitting up on the side of his/her bed. He/she had been incontinent of bladder and seemed to be trying to get up.
3. Review of Resident #52's quarterly MDS, dated [DATE], showed:
- A BIMS of 7 which indicated mild cognitive impairment;
- Extensive staff assistance with bed mobility and dressing, totally dependent on staff for transferring between surfaces, moving on and off the nursing unit, toilet usage and personal hygiene;
- Limited assistance with eating;
- Diagnoses included Alzheimer's disease, stroke, one sided paralysis, Parkinson ' s disease, malnutrition, oropharyngeal dysphagia (a term that describes swallowing problems occurring in the mouth and/or the throat), and a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar [dead tissue] may be present on some parts of the wound bed; often includes undermining and tunneling);
- Staff checked none of the above for swallowing disorders; these disorders included loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, complaints of difficulty or pain with swallowing;
- One Stage IV pressure ulcer which was present on admission.
Review of the resident's current physician's order sheet (POS) reviewed on 12/22/21, showed orders for a regular diet, pureed texture, regular/thin consistency, thin liquids with use of coffee straw only.
Review of the resident's care plan, printed on 12/22/21, showed the resident has potential nutritional problems related to dysphagia, Parkinson's disease, stroke, history of malnutrition and poor appetite. Staff implemented the following interventions:
- Will comply with recommended diet for weight reduction daily through review date.
- Administer medications as ordered. Monitor/Document for side effects and effectiveness.
- Monitor/document/report as needed (PRN) any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals.
- Monitor/record/report to physician PRN signs and symptoms of malnutrition: emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, greater than a 5% loss in 1 month, 7.5% in 3 months, 10% in 6 months.
- Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated.
- Occupational therapy to screen and provide adaptive equipment for feeding as needed: divided plate, lidded cups with handles;
- Provide and serve diet as ordered: Puree with Nectar thick liquids;
Registered dietitian (RD) to evaluate and make diet change recommendations PRN.
- Ready Care/Med pass supplement as ordered for wound healing
- Weigh weekly as tolerated.
Observation on 12/16/21 at 12:24 P.M., showed the resident sat in his/her wheelchair in dining room waiting for his/her meal. He/she had drinks in front of him/her with a regular straw in it.
During an interview on 12/22/21 at 4:22 P.M., the Director of Nursing (DON) and Administrator said they have to have orders for adaptive equipment. If a resident needed a special straw therapy would order thru central supply. They would communicate this in an in-service with staff and dietary will review. Therapy will write up a communication to nursing when off their case load, would be as an order for equipment.
4. During an interview on 12/22/21 at 3:52 PM. the MDS coordinator said she has been developing care plans and adding interventions She will discuss any changes with the charge nurses. Nurses can put interventions in place. Interventions should be put in place at the time of the occurrence or incident. She will usually tell the staff of the intervention, or the staff will suggest the intervention. Resident #52 should be using a coffee straw; with things like that usually therapy will tell the staff. She did not know if anyone is monitoring to ensure care plans are being followed.
Based on observation, interview, and record review, the facility failed to develop, implement and update a comprehensive person-centered care plan for three of 24 sampled residents (Residents #43, #52 and #71, ). The facility census was 104.
Review of the facility's Care Plan Revisions Upon Status Change, dated 11/1/21, showed:
-The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.
-The comprehensive care plan will be reviewed, and revised, as necessary, when a resident experiences a status change.
-Procedure for reviewing and revising the care plan when a resident experiences a status change:
f. Care plans will be modified as needed by the Minimum Data Set (MDS) Coordinator or other designated staff member.
h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.
1. Review of Resident #71's quarterly MDS, dated [DATE] showed:
-cognitively intact
-extensive to total assistance with Activities of Daily Living (ADL), including dressing, bed mobility and bathing
-limited range of motion to both upper extremities and both lower extremities
-no weight was recorded
-noted as having no skin issues
Observation and interview of Resident #71 on 12/14/21 at 9:32 AM showed:
-He/she lay in bed in a hospital gown. The gown was dirty with stains on the front and the resident's hair greasy and unkempt.
-He/she said:
-He/she is unable to get out of bed as there is not a lift in the facility that can handle his/her weight
-He/she has not been out of bed since August
-He/she is supposed to get bed baths, but it doesn't happen because there isn't enough staff.
-He/she has a wheelchair to use, but even if he/she could get out of bed, the wheelchair is too small and hurts to use it.
Review of the resident's care plan dated 11/3/21, showed:
-He/she prefers to bathe/shower 2-3 times per week, washing hair during bath/shower
-Requires assistance of 2 staff with bathing/showering twice weekly and as needed, using Hoyer lift
-Requires a mechanical lift Hoyer with 2 staff assistance for transfers. Uses wheelchair propels self.
-There were no problems or approaches addressing the resident's weight had exceeded the lift capacity and cannot be transferred from the bed
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** 3. Review of Resident #53's comprehensive MDS dated [DATE] showed:
-BIMS score of three, indicated that the resident has severe ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #53's comprehensive MDS dated [DATE] showed:
-BIMS score of three, indicated that the resident has severe cognitive ability;
-Extensive assistance of one person with ADL's;
-Frequently incontinent of urine and continent of bowels;
-Diagnoses of brain injury, heart failure, hypertension (HTN), arthritis, dementia, anxiety and depression.
During an observation on 12/13/21 at 1:39 P.M. showed the resident sitting in a wheelchair in the dining/activity room with a cushion in the wheelchair with a pommel (A pommel cushion prevents a wheelchair resident/patient from sliding down and possibly falling out of wheelchair.).
Review of the undated care plan for falls showed:
-The resident is at risk for falls related to Confusion , Incontinence, Unaware of safety needs , and wandering;
-Goal: The resident will be free of falls through the review date.
-Interventions/Tasks: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident is wearing appropriate footwear when mobilizing in wheelchair. Follow facility fall protocol. Physical therapy evaluate and treat as ordered or as needed. The resident resides on a secure unit. The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach.
During an interview on 12/16/21 at 10:00 A.M. LPN D said:
-Therapy gave the pommel cushion to the resident due to the resident sliding in the wheelchair, resident cannot stand on his own.
4. Review of the Resident #84's quarterly MDS dated [DATE] showed:
-Score of zero for the BIMS;
-Extensive assistance for ADL's, limited assistance for walking and locomotion;
-Incontinent of bowel and bladder;
-Diagnoses of HTN, diabetes, stroke, aphasia (inability to speak), seizure disorder, anxiety and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality).
Review of the resident's care plan for skin revised on 11/30/21 showed:
-Focus: Resident has a rash to his/her abdomen and under both arms and on 11/29/21 right foot second toe is black/moist, black spot on left foot;
-Goal: His/her rash will be healed. No goal documented for the black area to the second toe on the right foot or the black spot on the left foot;
-Interventions/Tasks: 11/29/21: Toe cleaned with wound cleanser and Tylenol given for signs/symptoms of pain while treating area. All parties notified.
Review of the care plan for skin showed no intervention for the black spot on the left foot.
Review of the the weekly skin check dated 12/8/21 showed:
-Scabs to the left knee. Dry dressing intact on toes on the right foot. Scab from blood blister on the fifth toe to the left foot.
Review of the hospital records dated 12/12/21 showed:
-Resident has a past medical history of dementia, hypertension, diabetes and necrotic right toe. The resident was recently admitted to another hospital for a necrotic second digit of the right foot. He/she was deemed not to be a surgical candidate for amputation of the right toe and was treated with IV (intravenous, an apparatus used to administer a fluid (as of medication, blood, or nutrients) intravenously) antibiotics and was discharged upon completion.
-The resident appears to have a blister/wound to the left foot. The left fifth toe/lateral aspect (outer portion of the foot) shows skin loss with erythema (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries). Tender to touch.
Review of the care plan showed no interventions for the open area to the left foot or any treatments to the right foot.
5. Review of Resident #12's quarterly MDS dated [DATE] showed:
-BIMS of five, indicated that the resident has severe cognitive ability;
-Supervision with Activities of Daily Living (ADL's);
-Continent of bowel and bladder;
-Diagnoses of HTN, Alzheimer's disease, diabetes;
-Received occupation and physical therapy;
-No restorative nursing.
Review of the Therapy Communication to Restorative Nursing Program dated 10/12/21 showed:
-Referred by Physical Therapy to Restorative Nursing;
-Current Functional Status: stand by assistance (SBA) with verbal cues;
-Problems/needs: maintain ambulation status;
-Goals of Intervention: Maintain independence and strength;
-Recommendations/approaches: seated therex (Therapeutic Exercise & Activity - TherEx & TherAc are the systematic and planned performance of body movements or exercises which aim to improve and restore function) if tolerates with three pound weights and walking with forward;
-Precautions: occasional stumbling/difficulty with obstacles;
-Assistance Required: stand by assistance (SBA)/contact guard assistance (CGA).
Review of the resident's medical record showed no documentation of the Restorative Nursing program and no care plan for the program.
6. During an interview on 12/14/21 at 2:39 P.M. the MDS Nurse said:
-Resident #84's only wound was on the second toe on the right foot. He/she was not aware of the wound to the left foot;
-He/she is notified of any new wounds or conditions in morning stand up meetings. Once this information is received, he/she will put interventions on the care plan or develop a care plan. Nurses can also update the care plans.
During an interview on 12/22/21 at 4:22 P.M. the Director of Nursing and Corporate Nurse B said:
-Resident Care plans should be appropriate, current and accurate with interventions;
-The care plan flows into the [NAME] (a tool used by the nursing staff to give care) in the electronic medical record with interventions for the staff to follow.
Based on observation, interview and record review, the facility failed to review and revise comprehensive care plans to be consistent with the residents' current condition and care needs. This effected five of 24 residents sampled (Resident #71, #68, #53 #84, and #12). The facility census was 104.
Review of the facility's Care Plan Revisions Upon Status Change, dated 11/1/21, showed:
-The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.
-The comprehensive care plan will be reviewed, and revised, as necessary, when a resident experiences a status change.
-Procedure for reviewing and revising the care plan when a resident experiences a status change:
f. Care plans will be modified as needed by the Minimum Data Set (MDS) Coordinator or other designated staff member.
h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.
1. Review of Resident #71's quarterly MDS, dated [DATE] showed:
-cognitively intact;
-extensive to total assistance with Activities of Daily Living (ADL), including dressing, bed mobility and bathing;
-limited range of motion to both upper extremities and both lower extremities;
-no weight was recorded;
-noted as having no skin issues.
Observation and interview of Resident #71 on 12/14/21 at 9:32 AM showed:
-He/she lay in bed in a hospital gown. The gown was dirty with stains on the front and the resident's hair greasy and unkempt.
-He/she said:
-He/she is unable to bet out of bed as there is not a lift in the facility that can handle his/her weight
-He/she has not been out of bed since August
-He/she is supposed to get bed baths, but it doesn't happen because there isn't enough staff.
-He/she has a wheelchair to use, but even if he could get out of bed, the wheelchair is too small and hurts to use it.
Review of the resident's care plan dated 11/3/21, showed:
-He/she prefers to bathe/shower 2-3 times per week, washing hair during bath/shower
-Requires assistance of 2 staff with bathing/showering twice weekly and as needed, using Hoyer lift
-Requires a mechanical lift Hoyer with 2 staff assistance for transfers. Uses wheelchair propels self.
-There are no problems or approaches addressing the resident's weight has exceeded the lift capacity and cannot be transferred from the bed
2. Review of Resident #68's admission MDS dated [DATE] showed:
- Score of zero on the Brief Interview for Mental Status (BIMS) (a structured evaluation aimed at evaluating aspects of cognition in elderly patients), indicating severely impaired cognition;
-No behaviors noted;
-Requires extensive assistance from staff for all activities of daily living;
-The resident has a catheter, is always incontinent of bowel.
Review of Resident #68's care plan dated 11/15/21 showed:
-The resident has a Foley catheter;
-Change catheter as ordered by physician and as needed for obstruction, soiled tubing, and damage;
-Check tubing for kinks each shift;
-Change Foley tubing securement device weekly and as needed if loose or soiled;
-Cleanse catheter with soap and water, rinse, pat dry every shift and as needed;
-Monitor and document catheter output each shift. Document on milliliters on Medication Administration Record (MAR);
-Monitor urine for change in color, consistency or odor. Notify physician and document findings and interventions as ordered.
Observation of Resident #68 on 12/16/21 at 4:45 P.M. showed:
-Resident lying in bed in room, lights off;
-No catheter tubing was observed.
During an interview on 12/16/21 at 4:47 P.M., Certified Nurse Aide (CNA) B said:
-Resident #68 does not have a catheter;
-CNA B is unsure when the catheter was removed.
During an interview on 12/16/21 at 4:52 P.M., Licensed Practical Nurse (LPN) B said:
-Resident #68 did not have a catheter
-He/she is unsure when the catheter was discontinued
Review of Resident #68's Physician Order's on 12/17/21 at 1:03 P.M. showed:
-No physician order for insertion of catheter;
-No physician order to discontinue to the use of the catheter.
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** 5. Review of Resident #98's comprehensive MDS dated [DATE] showed:
-Not able to answer questions;
-Supervision with ADL's;
-Exte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #98's comprehensive MDS dated [DATE] showed:
-Not able to answer questions;
-Supervision with ADL's;
-Extensive assistance with toileting;
-Incontinent of bowel and bladder;
-Diagnosis of Alzheimer's disease and depression.
Review of the undated care plan for self-care performance showed:
-Focus: the resident has an ADL self-care performance deficit related to Alzheimer's disease;
-Goal: The resident will receive appropriate support from staff with his/her ADL's;
-Interventions/Tasks: Toilet use: the resident requires assistance by one staff for toileting/incontinence cares, encourage the resident to use the call bell for assistance.
Review of the undated care plan for bowel and bladder showed:
-Focus: the resident has bowel and bladder incontinence related to Alzheimer's disease;
-Goal: The resident will remain free from skin breakdown due to the incontinence and brief use;
-Interventions/Tasks: The resident use disposable briefs, change as needed. Clean peri-area with each incontinence episode; ensure the resident has an unobstructed path to the bathroom.
Observation on 12/10/21 at 2:20 PM showed the resident leaving the dining room with an CNA. The back of the resident's pants was saturated with urine. The CNA walked the resident back to his/her room and stood the resident at the sink and pulled his/her pants down, removed a saturated brief and provided incontinent care.
-The CNA took the resident to the bathroom where the resident had a large bowel movement. The CNA walked the resident to his/her bed and laid him/her down and applied a clean brief. The CNA was unable to put on any pants, as the resident did not have any clothing in the closet.
During an interview on 12/10/21 at 2:30 P.M. Restorative Aide A said:
-The resident is incontinent of urine and needs help;
-He/she is not the resident's aide, he/she is giving showers on the hall;
-He/she is the restorative nursing aide;
-He/she has been pulled from doing Restorative Nursing to give showers;
-He/she is suppose to give showers to all of the residents;
-He/she tries to give each resident one shower a week, at times the evening shift will help;
-The facility currently does not have a designated shower aide for each hall.
During an interview on 12/22/21 at 4:22 P.M. the Director of Nursing and Corporate Nurse B said:
-The would expect the residents to be checked every 2 hours, prior to meals, after meals, activities and upon rounds for toileting needs.
Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living, including dressing, bathing and personal hygiene, to dependent residents. This affected five of 24 sampled residents (Residents #11, #54, #68, #71 and #98). The facility census was 104.
Review of the facility's policy on Activities of Daily Living (ADLs), dated 11/1/21, showed:
-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.
-Care and services will be provided for the following activities of daily living:
1. Bathing, dressing, grooming, and oral care;
2. Transfer and ambulation;
3. Toileting;
4. Eating to include meals and snacks; and
5. Using speech, language, or other functional communication systems.
-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
The facility was unable to provide shower sheets.
1. Review of Resident #71's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 10/27/21 showed:
-Cognitively intact;
-Extensive to total assistance with Activities of Daily Living (ADL), including dressing, bed mobility and bathing;
-Limited Range of Motion to both upper extremities and both lower extremities
-no weight was recorded;
-Noted as having no skin issues.
Review of the resident's care plan dated 11/3/21, showed:
-He/she prefers to bathe/shower 2-3 times per week, washing hair during bath/shower;
-Requires assistance of 2 staff with bathing/showering twice weekly and as needed, using Hoyer lift;
-Requires a mechanical lift Hoyer with 2 staff assistance for transfers;
-Uses wheelchair propels self.
Observation on 12/14/21 at 9:32 AM showed:
- The resident lying in bed in hospital gown;
- Gown was dirty with stains on front;
- The resident's hair appeared greasy and unkempt.
During an interview on 12/14/21 at 9:32 AM, the resident said:
-He/she is unable to bet out of bed as there is not a lift in the facility that can handle his/her weight;
-He/she has not been out of bed since August;
-He/she is supposed to get bed baths, but it doesn't happen because there isn't enough staff.
2. Review of Resident #68's admission MDS dated [DATE] showed:
-Zero on the Brief Interview for Mental Status (BIMS) (a structured evaluation aimed at evaluating aspects of cognition in elderly patients), indicating severely impaired cognition;
-No behaviors noted;
-Extensive assistance from staff for all activities of daily living;
-The resident has a catheter, is always incontinent of bowel.
Review of the resident's care plan dated 11/15/21 showed:
-The resident has an ADL self-care performance deficit related to Dementia
-The resident will receive appropriate support from staff with ADL's through next review date.
-Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.
-The resident requires assistance by one staff with showering twice weekly and as necessary
-The resident requires assistance by one staff to turn and reposition in bed;
-Make sure shoes/non-skid socks are comfortable and not slippery;
-Resident requires assistance by one staff to dress;
-Resident requires assistance by one staff for personal hygiene and oral care;
-Resident requires assistance by one staff for toileting/incontinence care.
Observation of Resident #68 on 12/14/21 at 2:48 P.M. showed:
-The resident wheeling down the hallway in a wheelchair;
-He/she was dressed in pants and long sleeve shirt. The shirt was dirty with stains, food matter;
-His/her hair was unkempt and appeared greasy.
Observation on 12/15/21 at 10:45 A.M. showed:
-The resident wearing the same clothing from the day before. The shirt continued to be dirty with stains and food matter;
-His/her hair continues to be unkempt and greasy.
3. Review of Resident #54's quarterly MDS dated [DATE] showed:
-14 on the BIMS, indicating the resident is cognitively intact;
-No behaviors noted;
-The resident requires limited to extensive assistance on activities of daily living.
Review of the resident's care plan dated 10/22/21 showed:
-The resident's desired personal care routine is showering in the afternoon, twice weekly, staff to assist with shaving on shower days, washing hair with showers.
-The resident has an ADL self-care performance deficit related to Parkinson's disease.
-Check nail length and trim and clean on bath day and as necessary. Report changes to the nurse;
-Requires assistance of one staff with showering;
-Provide sponge bath when full bath or shower cannot be tolerated;
-Allow sufficient time for dressing and undressing;
-Requires assistance with one staff for dressing;
-Requires assistance of one staff for personal hygiene and oral care;
-Requires assistance of one staff for incontinent care.
Observation on 12/14/21 at 9:16 A.M. showed:
-The resident had significant facial hair grown, at least a half inch;
-His/her nails long and with dark matter underneath;
-The resident's hair unkempt and appears greasy.
During an interview on 12/14/21 at 9:16 A.M., the resident said:
-There is not enough staff to shave and shower the residents;
-He/she cannot remember the last time he/she had a shower;
-He/she would like to be shaved at least every other day. The resident does not like to have long facial hair;
-He/she would also like to have his/her nails clipped. He/she likes them kept short.
4. Review of Resident #11's quarterly MDS dated [DATE] showed:
-15 on the BIMS, indicating the resident is cognitively intact;
-No behaviors noted;
-The resident requires extensive assistance with ADLs;
-The resident is at risk for developing pressure ulcers and has Moisture Associated Skin Damage.
Review of the resident's care plan dated 12/14/21 showed:
-The resident's desired personal care routine is preferring to shower, twice weekly, independent with shaving, and washing hair with showering;
-The resident has an ADL self-care performance deficit related to congestive heart failure (CHF- a serious condition in which the heart doesn't pump blood as efficiently as it should) and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of his lower extremities.
-Dependent on 1-2 staff to provide bath/shower twice weekly and as necessary;
-Provide sponge bath when a full bath or shower cannot be tolerated;
-Requires assistance of 1-2 staff to turn and reposition in bed;
-Requires assistance of 1-2 staff to dress;
-Requires assistance of 1-2 staff with personal hygiene and oral care;
-Dependent on 2 staff for incontinent cares;
-Requires mechanical lift with 2 staff assistance for transfers.
Observation on 12/13/21 at 2:25 P.M. showed:
-Resident in bed, wearing a hospital gown;
-Gown dirty with stains and food matter;
-Hair unkempt and appears greasy;
-The resident has facial hair grown of approximately a quarter of an inch.
During an interview on 12/13/21 at 2:25 P.M., the resident said:
-He/she rarely gets out of bed because there are never enough staff to use the mechanical lift, as it requires 2 staff at a time;
-He/she cannot use the bathroom in his/her room because he/she needs a lift to get out of bed, and the bathroom and bathroom door are too small to accommodate the resident's electric wheelchair. He/she has to use the bed pan, but would prefer to use the toilet;
-He/she is supposed to get two showers per week, on Tuesdays and Fridays. Since September, he/she feels they are lucky to get one shower per week;
-There are no staff specifically assigned to showers;
-He/she has skin issues and needs to shower frequently to prevent skin break down.
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** 3. Review of Resident #31's quarterly MDS, dated [DATE], showed:
-Unable to answer questions;
-Did the resident need an interpre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #31's quarterly MDS, dated [DATE], showed:
-Unable to answer questions;
-Did the resident need an interpreter marked no;
-The resident's preferred language was blank;
-Activity assessment completed by staff;
-The resident required supervision with ADL's;
-Diagnoses of hypertension, diabetes, and Alzheimer's disease.
Review of the undated care plan for communication problem related to language barrier showed:
-The resident had a communication problem related to language barrier. Spanish was his/her first language. He/she knew some simple English;
-Goal: He/she would be able to make basic needs known. May call family to help translate. Some staff speak Spanish;
-Interventions/Tasks: Allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Face when speaking, make eye contact. Turn off TV/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed; anticipate and meet needs; be conscious of resident position in groups, activities, dining room to promote proper communication with others; provide translator as necessary to communicate with the resident. Translator was the resident's family, staff, or the translation line.
-No care plan for activities.
During an interview on 12/13/21 at 2:38 P.M., Licensed Practical Nurse (LPN) D said:
-The resident does not speak English.
-He/she spoke Spanish and there was a therapist who speaks Spanish, otherwise there was no method of communication, some staff had apps on their phones that they can talk into for translation.
Observation on 12/14/21 at 10:00 A.M., showed the resident come to the nurses station speaking in Spanish. No staff could understand the resident. Staff walked the resident back to his/her room. The resident continued to speak quickly in Spanish.
-The Activity calendar in the resident's room was in Spanish;
Review of the activity participation review, dated 12/17/21, showed:
-Reason for review was a quarterly review;
-Sections resident interview, marital status, number of children, religion, and attendance summary was left blank;
-Past community organizations marked Catholic;
-MDS assessment of daily activity preference, important to choose clothes, personal belongings, choose between type of bath, have snacks, bedtime, phone, family or close friend involved in cares, use of a phone, keep valuables safe, choose books, newspapers or magazines to read, music, animals, news, groups, favorite activities, go outside, and participate in religious activities marked not assessed.
Observations during the survey period from 12/9/21 through 12/22/21 showed the resident did not participate in any activity program. The Activity Department did not provide any activity in Spanish or provide any religious service in Spanish.
4. Review of Resident #66's comprehensive MDS, dated [DATE], showed:
-Unable to determine language marked. In need of an interpreter was not marked;
-Unable to complete BIMS marked, indicating staff were unable to assess the resident's cognitive ability;
-Diagnoses of Alzheimer's, dementia, Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people.), anxiety, depression and Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).
Review of the resident's undated care plan for communication problem showed:
-The resident has a communication problem related to language barrier. The resident's was not able to read Korean (not able to read) knows pictures:
-Goal: The resident would be able to make basic needs known on a daily basis through the review date. The resident would maintain current level of communication function by: making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board through the review dated;
-Interventions/Tasks: anticipate and meet needs. Staff should allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Face when speaking, make eye contact. Turn off TV/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed; anticipate and meet needs; be conscious of resident position in groups, activities, dining room to promote proper communication with others. Resident required an I-pad translator to communicate. Ensure availability and functioning of adaptive communication equipment. Monitor effectiveness of communication strategies and assistive devices. Provide a program of activities that accommodates the residents communication abilities. The resident was working with speech therapy and communication translator.
Review of the resident's care plans showed no Activity Care plan.
Review of the resident's medical record on 12/12/21 at 12:33 P.M., showed:
-An activity assessment, dated 10/28/21, showed in progress with no section of the assessment as completed.
-An Activity Assessment, dated 11/21/ 21, for admission showed: the resident's spoke English was checked NO, understands English was left blank, other languages was marked no. The resident's liked arts and crafts, cooking/baking, cultural events, family/friends, pet visits. Communication devices used: Family. Other psychosocial, physical or environmental issues that might hinder or reduce activity: did not speak English and was unable to read English or Korean. Comments: I have called the family to get the assessment done and did not hear back. Source of information: observation.
-No documentation noted in the medical record for activity participation.
During an interview on 12/13/21 at 1:44 P.M. LPN D said:
-The facility had an interpreter line that can be called. The resident had a tablet that staff can talk into it and it will translate English to Korean, but the resident does not always understand due to his/her dementia.
-Staff had called his/her family to calm the resident.
During an interview on 12/14/21 at 12:49 P.M., Family Member B said:
-The resident did not speak English, the family had provided the resident with an Ipad that would translate English, but he/she felt the resident's dementia had progressed for him/her to understand the translation and the staff did not use the Ipad. The facility would call him/her at times to assist with translation. The facility does not provide any activities for the resident. He/she has offered to assist the facility with activities and communications, but the facility has not set up a meeting to discuss this.
Observations during the survey period from 12/9/21 through 12/22/21 showed the resident did not participate in any activity program other than coloring. The Activity Department did not provide any activity in Korean.
5. During an interview on 12/21/21 at 1:32 P.M. the Activity Director (AD) said:
-Resident #66 was picking up on a few English words and loved to color.
-The activity plan for non English speaking residents are to print out chronicles in Spanish and word searches. Resident #31 and #66 does not speak English , the AD assistant does one on one with him/her.
-Resident #14 did not see well and he/she needs a lot of sensory items needed;
-He/she had not reached out for any outside resources for activities for non English speaking residents. The facility had a bi-lingual resident that helps out.
-He/she had not created any type of book to assist. The facility had talked about a communication board for Resident #66. A family member had told them that the resident cannot read the Korean language.
- Do have a priest come in to pray, but the priest does not speak Spanish.
-He/she looked at the residents to determine if the resident was engaging in the activity and completed the assessment by observation. If there was a question that cannot be answered by observation he/she would call the families.
-He/she did individualize resident activity, but did not provide any individual activities for non English speaking residents.
-He/she was aware that all of the resident's could not speak English, but they did not have any activities for them in their languages.
Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities based on the comprehensive assessment and preferences of each resident. They failed to provide activities designed to encourage both independence and interaction within the facility. This affected four of 24 sampled residents (Resident #14, #68, #31, and #66 ) The facility census was 104.
Review of the facility policy for Activities, dated 11/1/2021, showed:
-It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility-sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community.
-Activities refer to any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive and emotional health.
-Activities will be designed with the intent to:
a. enhance the resident's sense of well-being, belonging and usefulness.
b. promote or enhance physical activity.
c. promote or enhance cognition.
d. promote or enhance emotional health.
e. promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence.
f. reflect resident's interest and age.
g. reflect cultural and religious interests of the residents.
h. reflect choices of the residents.
-Activities may be conducted in different ways:
a. one-to-one programs.
b. person appropriate-activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for.
c. program of activities- to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend.
-Special Considerations will be made for developing meaning activities for resident with dementia and/or special needs. These include, but are not limited to, considerations for:
a. residents who exhibit unusual amounts of energy or walking without purpose.
b. residents who engage in behaviors not conducive with a therapeutic home like environment.
c. residents who exhibit behaviors that requires a less stimulating environment to discontinue behaviors not welcomed by others sharing their social space.
d. residents who go through other' belongings.
e. residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of day.
f. resident to excessively seek attention from staff and/or peers.
g. resident who lack awareness of personal safety.
h. residents who have delusional and hallucinatory behavior that is stressful to themselves.
1. Review of Resident #68's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/8/2021, showed:
-Zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients), indicating severe cognitive impairment.
-The resident wandered 1-3 days during the evaluation period.
-The resident's family answered the questions for the Interview for Daily and Activity Preferences.
-The resident required extensive assistance from staff for activities of daily living
-The resident had the diagnoses of epilepsy, mental retardation, and dementia.
Review of the resident's care plan, dated 11/15/21, showed:
-The resident had little or no activity involvement related to disinterest.
-The resident will express satisfaction with type of activities and level of activity involvement when asked through the review date.
-Explain to the resident the importance of social interaction, leisure activity time. Encourage the resident's participation.
-Invite/encourage the resident's family members to attend activities with resident in order to support participation.
-Modify daily schedule, treatment plan as needed to accommodate activity participation as requested by the resident.
-Remind the resident that the resident may leave activities at any time, and was not required to stay for entire activity.
-The resident was able to color.
Observation on 12/15/21 at 10:45 A.M., showed the resident propelled self in his/her wheelchair in the hallway, tearful and talking to self. No group activities going on at this time.
Observation on 12/16/21 at 4:45 P.M., showed:
-The resident lying in bed with the lights off in the room;
-The resident was tearful and talking to self
-Conversation was attempted with the resident. The resident repeatedly said No, no, no. No group activities going on at this time.
During an interview on 12/15/21 at 11:21 A.M., Certified Nursing Assistant (CNA) B said:
-He/she had not observed staff doing one on one activities with the resident.
-The resident wanders frequently and can be combative.
During an interview on 12/16/21 at 4:30 P.M., the Activity Director (AD) said:
-The resident can be disagreeable and wanders a lot.
-It was difficult to do one on one activities with the resident, because he/she can be difficult to communicate with and frequently refuses.
2. Review of Resident #14's admission MDS, dated [DATE], included the following information:
- Speech clear, sometimes understands and responds adequately to simple, direct, communication only.
- Vision highly impaired and wears glasses.
- BIMS was a score of one, indicating severe cognitive impairment,
- Under list of preferred activities, staff checked all 20 activities as the resident's preferences.
- Dependent on staff for all cares.
-Required supervision with eating.
Review of the resident's care plan, dated 9/14/21, included the following:
- Resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. All staff to converse with resident while providing care.
- Provide with activity calendar. Resident needed one on one bedside or in room visits if unable to attend out of room activities.
- The resident had a communication problem related to language barrier. He/she spoke Spanish.
- Provide translator as necessary to communicate with resident. Translator was a family member. The facility also have staff who spoke Spanish.
Observation on 12/9/21 at 10:20 A.M., showed the resident sleeping in bed. He/she had an activity calendar hanging on his/her wall in Spanish, but they did not use big lettering so the resident could see it.
Observations during the survey period from 12/9/21 through 12/22/21 showed the resident did not participate in any activity program.
During an interview on 12/9/21 at 1:30 P.M., the Director of Nursing (DON) said Resident #14 only spoke Spanish. He said the facility used a Spanish translator via the telephone. They also could call a family member and occasionally a staff member to interpret for him/her.
During an interview on 12/9/21 at 2:10 P.M., attempted to speak with the resident. He/she only spoke Spanish. The resident could not understand any English, but would smile and pat the surveyor's hand.
During an interview on 12/14/21 2:21 P.M., Occupational Therapist (OT) B said he/she interprets for the resident most of the time. The resident wants to engage and communicate with people. He/she loved to sit in his/her doorway and watch people pass by. He/she did not go to many activities, because he/she cannot see. Activities staff put a calendar in his/her room in Spanish, but he/she was unable to read it. OT B said there are staff on each shift who can communicate with him/ her even if it's not in Spanish. They can communicate by gestures.
During an interview on 12/13/21 at 1:39 P.M., the AD said the resident spoke Spanish. He/she comes to some activities. There was another Spanish speaking resident who can talk to him/her. None of her activity staff spoke Spanish. The resident occasionally comes to activities. He/she seemed to like Zumba. He/she had two staff who are aides, and they get pulled to work on the floor. My staff also have to pass meal trays and feed residents. The resident and others need one to one activities, but my staff cannot get time to do one on ones, because they have to help on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 and care plan restorative services recommende...
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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 and care plan restorative services recommended by physical therapy and occupational therapy to assist residents to reach their highest practicable well-being for three residents (Resident #12, #53 and #84) out of 24 sampled residents. The facility census was 104.
Review of the facility policy for Restorative Nursing Programs, dated 11/1/21 showed:
-It is the policy of this facility to provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable levels;
-Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning;
-Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols;
-The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preference;
-The Restorative nurse and restorative aides receive additional training on restorative nursing program activities upon hire and as needed;
-Residents, as identified during the comprehensive assessment process, will receiving services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include: passive or active range of motion (PROM or AROM); splint or brace assistance; bed mobility training and skill practice; training and skill practice in transfers or walking; training and skill practice in dressing and/or grooming; training and skill practice in eating and/or swallowing; amputation/prosthesis care; communication training and skill practice;
-Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy;
-Potential candidates for restorative nursing services may be identified through one or more of the following processes: physical assessments; Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff; specialized rehabilitation assessments; in-house referrals due to unusual occurrence/events;
-The Restorative Nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented;
-A resident's Restorative Nursing plan will include: The problem, need, or strength the restorative tasks are to address; the type of activities to be performed; frequency of activities; duration of activities; measurable goal and target date;
-The discharging therapist, Restorative Nurse, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan;
-Restorative aides will implement the plan for the designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form;
-The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly.
1. The facility provided the survey team two separate lists of residents who were to be receiving Restorative Nursing Services. The list of residents were not the same.
2. Review of Resident #12's quarterly MDS, dated [DATE], showed:
-BIMS (Brief Interview for Mental Status, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) of five, indicated that the resident had severe cognitive ability;
-Supervision with Activities of Daily Living (ADL's);
-Continent of bowel and bladder;
-Diagnoses of hypertension (HTN), Alzheimer's disease, diabetes;
-Received occupation and physical therapy;
-No restorative nursing.
Review of the Therapy Communication to Restorative Nursing Program, dated 10/12/21, showed:
-Referred by Physical Therapy to Restorative Nursing;
-Current Functional Status: stand by assistance (SBA) with verbal cues;
-Problems/needs: maintain ambulation status;
-Goals of Intervention: Maintain independence and strength;
-Recommendations/approaches: seated therex (Therapeutic Exercise & Activity - TherEx & TherAc are the systematic and planned performance of body movements or exercises which aim to improve and restore function) if tolerates with three pound weights and walking with forward;
-Precautions: occasional stumbling/difficulty with obstacles;
-Assistance Required: stand by assistance (SBA)/contact guard assistance (CGA).
Review of the resident's medical record showed no documentation of the Restorative Nursing program and no care plan for the program.
3. Review of Resident #53's comprehensive MDS, dated [DATE], showed:
-BIMS of three, indicated that the resident had severe cognitive ability;
-Extensive assistance of one person with ADL's;
-Frequently incontinent of urine and continent of bowels;
-Diagnoses of brain injury, heart failure, HTN, arthritis, dementia, anxiety and depression.
Review of the Therapy Communication to Restorative Nursing Program, dated 12/13/21, showed:
-Referred by Physical therapy;
-Current Function Status: varies on resident participation, minimum to maximum assistance;
-Problems/needs: weakness and instability;
-Goad of Intervention: maintain functional mobility;
-Recommendations/Approaches: complete both lower extremities (BLE) exercises with 25 pound weights and complete sit to stand transfers;
-Precautions: aggressive, agitation, poor positioning and retro lean (looses balance and falls backwards);
-Assistance Required: minimum to maximum assistance.
Review of the resident's medical record showed no documentation of the Restorative Nursing Program and no care plan for the program.
4. Review of Resident #84's Review of the Therapy Communication to Restorative Nursing Program, dated 10/26/21, showed:
-Current functional status: hand held assistance (HHA) for directional cues;
-Problems/needs: decreased balance and safety awareness;
-Goals of Intervention: maintain functional mobility;
-Recommendations/approaches: use HHA to ambulate with resident;
-Precautions: poor cognition, fall risk;
-Assistance required - HHA.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Zero for BIMS;
-Extensive assistance for ADL's, limited assistance for walking and locomotion;
-Incontinent of bowel and bladder;
-Diagnoses of HTN, diabetes, stroke, aphasia (inability to speak), seizure disorder, anxiety and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality);
-No Restorative Nursing Program.
Review of the medical record showed no documentation of the Restorative Nursing program or a care plan for Restorative Nursing.
5. During an interview on 12/16/21 at 10:06 A.M., Restorative Aide (RA) A said:
-He/she was the Restorative Aide;
He/she did the monthly weights and now he/she did the showers for the entire building.
-He/she had not had a chance to do Restorative Nursing for several months due to being pulled to the floor to work as a Certified Nurse Aide (CNA) and to do showers.
During an interview on 12/16/21 at 2:00 P.M., the Administrator said:
-She was the former therapy program manager until he/she was promoted to the Administrator's position;
-Therapy will write up the restorative program, give the program to the program manager, who will then to Director of Nursing (DON), and then Restorative Aide.
-The DON was suppose to put in Restorative program Point Click Care (PCC, the electronic medical record) so the Restorative Aide can see what tasks are to be done. The Restorative Aide documents in PCC .
During an interview on 12/22/21 at 3:52 P.M., the MDS Coordinator said:
-She had not been writing any Restorative Nursing care plans due to not having a Restorative Aide. The Restorative Aide had been pulled to work the floor as the shower aide and a CNA.
-Restorative Nursing had not been done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility census was 104.
The facility did not p...
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Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility census was 104.
The facility did not provide a policy for RN staffing.
Review of the staffing sheets for October 2021 showed:
-One RN worked for 8 consecutive hours on 10/20/21, 10/21/21, and 10/22/21;
-There was no RN for eight consecutive hours on the staffing sheets for the other days in October 2021.
Review of the staffing sheets for November 2021 showed:
-No RN scheduled on November 1, 2, 3, 8, 13, or 28 for eight consecutive hours.
Review of the staffing sheets for December 2021 showed:
-No RN scheduled for eight consecutive hours on 12/11/21, 12/12/21, or 12/13/21.
During an interview on 12/16/21 at 2:00 P.M., the Administrator said:
-This was her first day as administrator;
-She knows that there had been a high turnover in nurses and not for sure if the facility had enough RNs to work;
-She would expect that the facility would staff an RN for eight consecutive hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
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 medically-related social services to attain or...
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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 medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for six sampled residents. The facility failed to provide an interpreter or other methods to communicate with two non-English speaking residents (Residents #31 and #66); failed to involve the resident (Resident #84) and/or the resident's representative in care plan meetings; failed to obtain a Power of Attorney or Guardianship paperwork for one resident (Resident #86) residing on the locked behavioral unit who has a psychiatric diagnosis and the incapacity to make sound judgement involving their care; failed to ensure one resident (Resident #85) received proper treatment and assistive devices to maintain hearing abilities when they failed to make an appointment with an audiologist when the resident needed hearing aides; and failed to provide a comfortable chair for one resident (Resident #19) when he/she expressed that sitting in a plastic chair caused him/her undue pain. The facility's census was 104.
Review of the position description for the social services director, dated 3/5/21, showed the social services director is responsible for assisting in the planning, organizing, implementing, evaluating and directing of the social services department in accordance with current existing Federal, State and local standards as well as facility policies and procedures, to ensure that the medically-related emotional and social needs of the resident are met and/or maintained on an individual basis. The responsibilities and duties included assisting in obtaining resources from community social, health and welfare agencies to meet the needs of the resident.
Review of the facility policy for Social Services, dated 11/1/21, showed:
-The facility, regardless of size, will provide medically-related social services to each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;
-Medically-related social services are services provided by the facility staff to assist residents in attainment or maintenance of a resident's highest practicable well-being;
-The social worker, or social worker designee, will pursue the provision of any identified need for medically-related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline(s).
-Services to meet the resident's needs may include:
-Assisting or arranging for a resident's communication needs through the resident's primary method of communication or in a language that the resident understands;
-Maintaining contact with the family (with the resident's permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning;
-Assisting with informing and educating residents, their family and/or representative(s) about health care options and their ramifications;
-Assisting residents with advance care planning, including but not limited to completion of advance directives;
- Making arrangements for obtaining items, such as adaptive equipment, clothing, and personal items;
- Making referrals and obtaining needed services from outside entities (examples include talking books, absentee ballots, community wheelchair transportation).
-The resident's plan of care will reflect any ongoing medically-related social service needs, and how these needs are being addressed;
-The social worker, or social service designee, will monitor the resident's progress in improving physical, mental, and psychosocial functioning.
The facility did not provide a policy for Power of Attorney or Guardianship.
Review of the facility policy for Communicating with Persons with Limited English Proficiency, dated 11/1/21, showed:
-It is the policy of this facility to take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. The purpose of this policy is to ensure meaningful communication with LEP residents and their authorized representatives involving their medical conditions and treatment;
-Facility staff will identify the language and communication needs of the LEP person during the pre-screening and admission process;
-All interpreters, translators, and other aides needed by the resident and/or representative will be provided without cost to the person being served;
-The resident and/or representative will be informed of the availability of language assistance free of charge. The notification will be written in the language the LEP person understands at the time of admission. Additional postings will be located on bulletin boards of each nursing unit;
-Notification of the availability of language assistance services will also be provided through one or more of the following: outreach documents, telephone voice mail menus, and/ the facility's website;
-Language assistance will be provided through use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, or technology and telephonic interpretation services;
-The Social Services Director (SSD) will be responsible for obtaining access to a qualified interpreter. In the absence of the SSD, the responsibility will fall to the Director of Nursing (DON) or Nurse Manager on duty. Tasks include, but are not limited to: maintaining an accurate and current list showing the name, language, phone number and hours of availability of bilingual staff. The list will be accessible of all staff (provide the list) who may have direct contact with LEP individuals (specify where copies of the list are located);
-contacting the appropriate bilingual staff member to interpret, in the event that an interpreter is needed, if an employee who speaks the needed language is available and is qualified to interpreter;
-obtaining an outside interpreter if a bilingual staff or staff interpreter is not available or does not speak the needed language;
-maintaining an accurate and current list showing the name of the agency or interpreters with whom the facility has contracted or made arrangements to provide qualified interpreter services (provide the list);
-The resident and his/her representative will discuss plans and goals for communication with facility staff so that care is individualized to meet the resident's needs.
The facility did not provide a care plan for resident/family involvement with the care planning process.
1. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/17/21 showed:
-language: does the resident need an interpreter: no; preferred language: blank;
-BIMS (Brief Interview for Mental Status - It is a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) of two, which means the resident is unable to make decisions;
-No behaviors;
-Diagnoses of Hypertension (HTN), diabetes, and Alzheimer's disease.
Review of the undated care plan for communication problem related to language barrier showed:
-The resident has a communication problem related to language barrier. Spanish is his/her first language. He/she knows some simple English;
-Goal: He/she will be able to make basic needs known. May call family to help translate. Some staff speak Spanish;
-Interventions/Tasks: Allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Face when speaking, make eye contact. Turn off TV/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed; anticipate and meet needs; be conscious of resident position in groups, activities, dining room to promote proper communication with others; provide translator as necessary to communicate with the resident. Translator is: family, staff or the translation line.
Observation on 12/14/21 at 10:00 A.M., showed the resident went to the nurses station speaking in Spanish. No staff could understand the resident. Staff walked the resident back to his/her room. The resident continued to speak quickly in Spanish.
Observation on 12/16/21 at 12:35 P.M. showed:
-Resident #31 was sitting at the dining room table with a plate of food in front of him/her, another resident sat across the table from him/her, Resident #31 would take a spoon of food and hand it to the other resident, staff saw this and told the resident in English not to give the other resident the food. Resident #31 shook her hand up and down and continued to hand the other resident spoon fulls of food. Staff continued to speak to the resident in English, the resident could not understand what the staff was telling him/her. Staff finally took the utensils away from the resident.
During an interview on 12/21/21 at 2:35 P.M., Licensed Practical Nurse (LPN) D said:
-The resident does not speak English. LPN D speaks a little Spanish and there is a therapist who speaks Spanish, otherwise there is no method of communication. Some staff have applications (apps) on their phones they can talk into for translation. There is no communication board in the residents room. There is no translator line for the staff to use.
During an interview on 12/22/21 at 4:22 P.M., the Corporate Registered Nurse and Interim Director of Nursing said:
-Social Services should contact the families of non-English speaking residents to determine the method of communication for those residents.
2. Review of Resident #66's comprehensive MDS, dated [DATE], showed:
-Language: Unable to determine; Needs an interpreter: not marked;
-Staff were unable to assess the resident's cognitive ability;
-Diagnoses of Alzheimer's, dementia, Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), anxiety, depression and Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).
Review of the undated care plan for communication problem showed:
-The resident has a communication problem related to language barrier. Is not able to read Korean (not able to read, period), knows pictures:
-Goal: The resident will be able to make basic needs known on a daily basis through the review date. The resident will maintain current level of communication function by: making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board;
-Interventions/Tasks: Anticipate and meet needs. Allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Face when speaking, make eye contact. Turn off TV/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed; anticipate and meet needs; be conscious of resident position in groups, activities, dining room to promote proper communication with others. Resident requires an I-pad translator to communicate. Ensure availability and functioning of adaptive communication equipment. Monitor effectiveness of communication strategies and assistive devices. Provide a program of activities that accommodates the resident's communication abilities. The resident is working with speech therapy and communication translator. Call his/her Power of Attorney also.
Observation and interview on 12/10/21 at 2:00 P.M. showed:
-The Resident was walking down the hall with hands on his/her belly with grimacing. Certified Medication Technician (CMT) A walked up to resident and asked the resident what was wrong in English, the resident shook his/her head and continued to hold his/her belly moaning.
-CMT A looked at the surveyor and said that he/she thought the resident's hip may hurt and told the surveyor I wish I could understand him/her.
- CMT A said that a therapist has a tablet with apps on it, and that is how they communicate with him/her. There is no I-pad for the staff to use, the one they had has been broken for some time;
-He/she is not aware of any interpreter line to call, there is no way to communicate with the resident.
-Approximately 15 minutes later, CMT A came to the surveyor and said that the resident must have the stomach bug because the resident just threw up.
During an interview on 12/13/21 at 1:44 P.M., LPN D said:
-The facility has an interpreter line that can be called. The resident has a tablet that staff can talk into it and it will translate English to Korean but the resident does not always understand due to his/her dementia.
-The resident does not have a communication board. A communication board could be useful;
-Staff has called his/her family to calm the resident.
During an interview on 12/14/21 at 12:49 P.M., Family Member B said:
-The resident does not speak English, the family has provided the resident with an Ipad that will translate English, but he/she feels the resident's dementia has progressed for him/her to understand the translation and the staff does not use the Ipad. He/she has not been contacted to work on a communication board for the resident to use, he/she has worked with the last facility that the resident was at on a communication board and it helped with communication. The facility will call him/her at times to assist with translation.
-He/she has not been invited to any care plan meetings to discuss the resident's plan of care.
Review of the resident's medical record on 12/20/21 at 3:58 P.M., showed no documentation in the medical record of family being invited to the care plan meeting.
During an interview on 12/22/21 at 4:22 P.M., the Corporate Registered Nurse and Interim Director of Nursing said:
-Social Services should contact the families of non-English speaking residents to determine the method of communication for those residents.
3. Review of Resident #84's quarterly MDS dated [DATE] showed:
-admitted to the facility on [DATE];
-The resident is not alert or able to answer questions;
-Extensive assistance of staff for ADL cares;
-Diagnosis of hypertension, diabetes and stroke.
During an interview on 12/14/21 at 12:48 P.M., Family Member A said:
-He/she has not been invited to any care plan meeting since the resident was admitted to the facility.
Review of the medical record on 12/20/21 at 3:58 P.M., showed no documentation of family being invited to the care plan meeting.
During an interview on 12/21/21 at 3:33 P.M., the MDS coordinator said:
-The Social Services Director (SSD) was in charge of notifying the family and inviting them to the care plan conference. The facility has not had a SSD for several months. The care plan meeting invitation should be in the progress notes. There have not been any families in attendance for the care plan meetings.
During an interview on 12/22/21 at 4:22 P.M., the Corporate Registered Nurse and Interim Director of Nursing said:
-The MDS coordinator is responsible for inviting the family and the resident to care plan meetings. The care plan meetings should be documented on a calendar, the letter for the invitation should be uploaded in the electronic medical record.
4. Review of Resident #86's quarterly MDS, dated [DATE], showed:
-admitted to the facility on [DATE];
-Alert with some confusion;
-Independent with ADLs;
-Diagnoses of hypertension, seizure disorder, bipolar disease (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), TBI (traumatic brain injury).
Review of the medical record on 12/14/21 showed:
-Social Services Note dated 5/3/2021 at 10:34 A.M. signed by the former Social Services Director : Resident admitted to facility yesterday from another long term care facility. Resident will reside in room [ROOM NUMBER]B on Village where he/she will have a roommate. Resident has a diagnosis of TBI, bipolar disorder, and other diagnoses. Resident is alert and oriented with much confusion and poor memory. Resident scored 12 on his/her BIMS. Resident will be a full code while in the facility. Resident's family was contacted regarding POA (Power of Attorney) but no response. Resident does not have any paperwork stating that he/she has a POA or guardian. Resident's family member is listed as a contact. Resident expresses that he/she wants to go and live with his/her mother in New York. Resident is calm at this time but is an elopement risk. Resident to be evaluated by facility doctor for admission and incapacitation. Family not available via telephone for visitation information. Resident to remain in the facility long term at this time.
-6/1/2021 at 3:45 P.M.- Social Service Note- Faxed information to the doctor on resident needing incapacitation evaluation.
-7/13/2021 at 12:21 P.M.- Social Services Note- Reached out to family member regarding DPOA (Durable Power of Attorney) paperwork but no response. Will continue to reach out.
Review of the medical record showed a Certificate of Capacity (a form used and signed by two physicians certifying a resident is incapacitated and unable to make decisions), signed by one physician and dated 7/7/21 with the second physician signature of 8/12/21.
Review of the resident's medical record on 12/14/21 at 11:16 A.M., showed the resident is a full code. A letter of incapacitation is on file. There is no POA on file or no guardianship paperwork on file.
During an interview on 12/22/21 at 4:22 P.M., the Corporate Registered Nurse and Interim Director of Nursing said:
-Social Services should ensure that before a resident has letters of incapacitation signed, that there is a power of attorney in place. If there is no power of attorney in place, then guardianship should be considered.5. During an interview on 12/13/21 at 3:47 P.M., the resident said he/she requested an appointment for a hearing test several months ago. They scheduled him/her for the hearing exam with an audiologist but that provider did not take his/her insurance. He/she thinks the facility has attempted to find someone who will take his/her insurance, but has not heard anything in a while. No one has given him/her any other information about the status of finding him/her an audiologist to get him/her tested and fit for hearing aids.
Review of Resident #85's quarterly MDS, dated [DATE], showed:
- Adequate ability to hear - no difficulty in normal conversation, social interaction, listening to television; no hearing aid or other hearing appliances used;
- A brief interview for mental status (BIMS) score of 15, which indicated no cognitive impairment.
Review of the resident's current care plan, printed on 12/10/21, showed staff had not developed any interventions for the resident's hearing loss.
Review of the interdisciplinary progress notes showed:
- On 5/26/21- Social worker to discuss options for getting resident a hearing test;
- On 6/22/21- Social service notes: Hearing exam scheduled for resident for July 6.
- No other notes regarding finding the resident a provider to provide the audiology services.
Review of the resident's medical record show no documentation to indicate the resident saw an audiologist or ever received any hearing exam or fitting for hearing aids.
During an interview on 12/15/21 at 2:15 P.M., the previous administrator said she was handling the social services issues, but did not know about the issues with the resident's hearing exam or the possible need for hearing aids. As far as she knew the resident had not been to the audiologist to get fitted for hearing aids.
During an interview on 12/16/21 at 3:45 P.M., the Marketing Director said he has been covering for the social services staff because they do not have one at this time. He did not know anything about the resident's hearing aids.
6. During an interview on 12/13/21 at 12:30 P.M., the previous administrator said they did not have a social services director at this time. She had been trying to handle all of the social services issues, but it was difficult with trying to cover the administrator roll as well as having to work the floor because of staffing. She knew things had fallen through the cracks. She thought they had a person hired to cover those duties who was to start on 12/20/21.
During an interview on 12/22/21 at 5:20 P.M., the Regional [NAME] President said they had a social services person hired who was to start on 12/20/21, however, after all of the documents they believe have been destroyed by previous employees, they have decided to go a different direction.
7. Review of the resident's admission diagnoses showed they included multiple rib fractures (right side) and Spondylosis (a painful condition of the spine resulting from the degeneration of the intervertebral disks) with myelopathy (disease of the spinal cord) or radiculopathy (a disease of the root of a nerve, such as from a pinched nerve) of the thoracic region (middle segment of the vertebral column).
Review of the resident's admission MDS, dated [DATE]/21, showed the following:
- Brief Interview for Mental Status (BIMS) score of 12 which indicates the resident was cognitively intact;
- Required limited staff assistance with ambulation, extensive staff assistance with dressing, and staff supervision with transfers and personal hygiene;
- No pain.
Review of the only pain assessment found in Resident #19's medical record, dated 9/6/21, showed the question is the resident experiencing pain and staff wrote no. No other information was filled out on the form.
Review of the Treatment Administration Record (TAR), dated December 2021, showed staff were to assess the resident for pain every shift. The resident's pain ranged from zero, indicating no pain, to a nine, indicating severe pain, one night shift. The resident did not have pain every shift.
During an observation and interview on 12/9/21 at 10:25 A.M., showed the resident sat in a plastic straight back chair. The chair did not have any padding or a way for the resident to change positions. The resident said he/she had pain in his/her lower back. The resident said he/she did not have a better chair to sit in. The facility only provided the plastic chair and it hurt his/her back to sit in it. It would be a dream to have a recliner.
Review of the resident's significant change of condition MDS, dated [DATE], included the following information:
- BIMS score of 12 which indicates the resident was cognitively intact;
- Independent with all ADLs;
- Resident had pain in the last five days;
- Had not received as needed pain medications;
- Had not received non-medication interventions for pain relief;
- Rated pain a seven (score of one is mild).
During an interview on 12/14/21 at 11:08 A.M., the resident said he/she had a lot of back pain. Staff gave him/her Tylenol, but it does not help. He/she gets Hydrocoodone (pain medication) three times a day.
During an interview on 12/20/21 11:47 A.M., the facility administrator said nursing should tell therapy if the resident required any equipment. If a resident needed a comfortable chair then that would be a social services issue and the former administrator was handling that since the facility did not have a SSD. The Administrator was not aware that the only chair in the resident's room was a straight back chair. The resident should have a comfortable chair.
Review of the facility's policy for pain management, dated 11/1/2021, included the following information:
- The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
- The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal.
- Non-pharmacological interventions will include but are not limited to environmental comfort measures (such as adjusting room temperature, smoothing linens, comfortable seating or assistive devices).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP) identified any attempts for g...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP) identified any attempts for gradual dose reduction (GDR) in an effort to reduce or discontinue psychoactive medications for five of 24 sampled residents (Residents #11, #54, #69, #88 and #97). The facility census was 104.
The facility did not provide a policy for Consultant Pharmacy services and/or GDR.
1. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/8/21, showed:
-The resident was alert and oriented and able to answer questions;
-Diagnoses of heart failure (HF), hypertension (HTN), diabetes (DM), anxiety and depression;
-Received 7 days of antianxiety and antidepressant medication.
Review of the Physician's Order Sheet (POS), dated 12/21, showed:
-Trazodone HCl Tablet 50 milligrams (mg) (used to treat depression, anxiety, or a combination of depression and anxiety);
-Hydroxyzine Pamoate 100 mg (may be used short-term to treat anxiety);
-Zoloft Tablet 100 mg (used to treat depression).
Review of the medical record showed no documentation of pharmacy recommendations for the review or recommended gradual dose reduction.
2. Review of Resident #54's quarterly MDS, dated [DATE], showed:
-Alert and oriented;
-Diagnoses of HTN, DM, dementia, Parkinson's (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), depression, manic depression (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and Schizophrenia (symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation);
-Received 7 days of antipsychotic (a type of psychiatric medication to treat psychosis), 7 days of antianxiety medication and 7 days of antidepressant medication.
Review of the POS, dated 12/21, showed:
-Lorazepam Tablet 0.5 mg (it can help to relieve anxiety);
-Depakote Tablet Delayed Release 500 mg (used to treat seizure disorders and certain psychiatric conditions (manic phase of bipolar disorder));
-Quetiapine Fumarate Tablet 50 mg (used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression));
-Sertraline HCl Tablet 100 mg (used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder).
Review of the medical record showed no documentation of pharmacy recommendations for the review or gradual dose reduction.
3. Review of Resident #69's comprehensive MDS, dated [DATE], showed:
-Alert and oriented with some confusion;
-Diagnoses of stroke, atrial fibrillation (a heart arrhythmia (when the heart beats too slowly, too fast, or in an irregular way)), coronary artery disease (when the major blood vessels that supply your heart become damaged or diseased), HTN, dementia and seizure disorder.
Review of the POS, dated 12/21, showed:
- Lorazepam Tablet 0.5 mg every 12 hours as needed for anxiety;
- Mirtazapine (used to treat depression.) 30 mg- give 1 tablet orally at bedtime related to Adjustment disorder with depressed mood;
-Trintellix (may improve your mood, sleep, appetite, and energy level and may help restore your interest in daily living) 20 mg one tablet daily related to Adjustment disorder with depressed mood;
- Rexulti (used to treat major depressive disorder) 1 mg- give 1 tablet orally one time a day related to Adjustment disorder with depressed mood.
Review of the medical record showed:
-12/16/2021 Pharmacy Note: Medication Record Review (MRR) completed, no recommendation at this time;
-9/24/2021 Pharmacy Note: MRR completed, please see report for recommendation;
-8/24/2021 Pharmacy Note: MRR completed, no recommendation at this time;
-7/28/2021 Pharmacy Note: MRR completed, please see report for recommendation;
-6/18/2021 Pharmacy Note: Pharmacist Consult: MRR completed;
-5/24/2021 Pharmacy Note: Pharmacist Consult: MRR completed;
-4/26/2021 Pharmacy Note: Pharmacist Consult: MRR completed;
-3/28/2021 Pharmacy Note: MRR completed.
Review of the medical record showed no physician's progress notes to show any reasons for not attempting a GDR, nor physician's progress notes addressing the recommendations on 9/24/21.
4. Review of Resident #88's comprehensive MDS, dated [DATE], showed:
-Alert and oriented;
-Diagnoses of stroke, atrial fibrillation, heart failure, HTN, anxiety and depression;
-Received 7 days of antianxiety and antidepressant medication.
Review of the POS, dated 12/21, showed:
-Alprazolam Tablet 1 mg ( used to treat anxiety and panic disorders);
-Sertraline HCl Tablet 50 mg.
Review of the medical record showed no pharmacist review for GDR and no physician recommendation for GDR.
5. Review of Resident #97's comprehensive MDS, dated [DATE], showed:
-Alert with some confusion;
-Diagnoses of dementia and anxiety;
-Received 7 days of antianxiety and antidepressant medication.
Review of the POS, dated 12/21, showed:
-Paroxetine HCl Tablet (used to treat depression, panic attacks, obsessive-compulsive disorder (OCD), anxiety disorders, and post-traumatic stress disorder) 20 mg;
-Buspirone HCl Tablet 15 mg (indicated for the management of anxiety disorders or the short-term relief of the symptoms of anxiety).
Review of the medical record showed:
-Pharmacist's progress notes, dated 12/16/21, and no recommendations for a GDR;
-On 11/23/21, the pharmacist wrote to see recommendations in the MRR. Review showed no MRR.
Review of the medical record showed no documentation of the GDR, or documentation of the physician being notified of the pharmacist's recommendation.
6. During an interview on 12/22/21 at 4:30 P.M., the Director of Nursing and Corporate Nurse B said:
-The pharmacist will provide his/her recommendations to the DON so the DON can contact the physician with the recommendations;
-She cannot find any pharmacist recommendations;
-The recommendations should be kept in the DON's office in a binder;
-Once the pharmacist makes the recommendations, they are sent to the resident's physician for review;
-Once the physician returns the recommendations, they are scanned in the resident's electronic medical record and the nurses carry out any orders that have been given;
-There are no pharmacist recommendations in the office and she cannot find any pharmacist recommendations.
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** 2. During an observation and interview on [DATE] at 9:59 A.M. with LPN D, of the nurse cart on Village hall showed:
- Loperamide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation and interview on [DATE] at 9:59 A.M. with LPN D, of the nurse cart on Village hall showed:
- Loperamide (used to treat diarrhea- 2 pills loose in top drawer;
-Vancomyacin (used to treat bacterial infection) 125 mg two tablets in a bag in the top drawer, the medication had an order discontinued [DATE]. LPN D said when the resident came back from hospital, he/she was started on Vancomyacin 125 mg. The Vancomyacin 125 mg tablets should be returned to pharmacy or given to Unit Manager.
-The Unit Manager used to go through the carts weekly and pulled out expired medication and discontinued medication, but he/she had not done this in a while due to having to work the floor.
-A full bottle of Haloperidol (used to treat behaviors) oral concentrate 2 mg/ml 30 mg. LPN D said that the resident had expired on [DATE];
3. Observation [DATE] at 11:34 A.M., on the Maple hall showed:
- 2 containers of Ready care high calorie supplement - one opened with date of [DATE], sitting on the medication cart, not on ice. The container showed to refrigerate once open and use within 3 days.
4. Observation and interview on [DATE] at 10:22 A.M., showed:
-Certified Medication Technician (CMT) C was the CMT for the Maple hall;
-Approximately 22 loose pills in the 2nd drawer of the medication cart;
-A card of Atorvastin 40 mg - take one tablet daily with an expiration date of [DATE] with a use by date of [DATE];
-Hydrocort 10 mg take one tablet daily, with an expiration date of [DATE] with a use by [DATE];
-CMT C said he/she was not for sure who was supposed to clean the cart. He/she was unaware of the medications being expired and the resident does not have an order for these medication.
-He/she assumed it was the CMT's job to go through and clean the carts.
-He/she was unsure who goes through the cart for expired medication.
During an interview on [DATE] at 2:00 P.M., the Director of Nursing said:
-Nurses or CMTs should be cleaning the medication carts.
-The Assistant Director Of Nursing (ADON) should be checking the carts for expired medication and medication that was opened, but since they do not have an ADON, the nurses should should be checking.
-Nurses and CMTs are expected to date when they open the bottle.
Based on observation, interview, and record review, the facility staff failed to store medications and biologicals in safe, clean, and sanitary conditions. This affected one of two sampled medication storage rooms and three of four sampled medication carts. The facility census was 104.
Review of the facility policy titled Medication Storage, dated [DATE], included the following:
- It is the policy of the facility to ensure all medications housed in the medications rooms are stored to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
- All medications and biologicals are stored in locked compartments such as medication carts, cabinets, drawers, refrigerators, and medications rooms, under proper temperature controls.
- All medications requiring refrigeration are stored in refrigerators located in each medication room.
- Temperatures are maintained within 36-46 degrees Fahrenheit. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or designee.
- In the event that a refrigerator is malfunctioning, the person discovering the malfunction must promptly report such finding to the maintenance department for emergency repair.
1. Observation of the HBU medication room on [DATE] at 10:22 A.M., showed the following:
- In the top right cabinet were the following medications (labeled with residents' names): A bottle of Levemir INJ (long acting insulin) label that says Keep Refrigerated, medication dated [DATE], the cap was popped off, and the bottle was almost full;
- Five medication cards from discharged residents containing Doxycycline (antibiotic) 100 milligrams (mg), Augmentin (antibiotic) 500/125 mg, Plavix (blood thinner) 75 mg, Losartan (treats high blood pressure) 50 mg, and Lipitor (lowers cholesterol) 80 mg.
-There was a plastic bag containing insulin pens and bottles of insulin. All of them said to keep refrigerated.
- There was one medication card Olanzapine (used to treat mental disorders including schizophrenia and bipolar disease) 5 mg from a discharged resident.
- The medication room refrigerator had a thermometer and it showed the temperature in the refrigerator was 28 degrees Fahrenheit. There were two towels in the bottom of refrigerator and next shelf up that were frozen. There was a yellow bucket with insulin pens and bottles of insulin stored in the bucket. There were frozen paper towels in the bottom of the bucket. There was a bottle of Humulin R insulin (short acting insulin) that was opened, but no date on it to show when it was opened. There was one bottle of Tubersol (solution used to test for tuberculosis (TB)) house stock in the bucket as well. The MDS coordinator verified that the insulin was up against the frozen paper towels.
During an interview on [DATE] at 10:45 A.M., the MDS nurse said he/she was not aware that the medication room refrigerator was set so low. He/she thought maybe someone had defrosted it a few days before and did not get it set right.
During an interview on [DATE] 11:51 A.M., the Director of Nursing (DON) said she did not know the refrigerator in the HBU medication room was set to freezing. She said insulin and other medications should not be kept below freezing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to honor resident preferences for meals and failed to follow the posted menu. The facility census was 104.
A review of the faci...
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Based on observation, interview, and record review, the facility failed to honor resident preferences for meals and failed to follow the posted menu. The facility census was 104.
A review of the facility's Menus and Adequate Nutrition policy, dated 11/1/21, showed:
-The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines.
-1. The facility will ensure that menus meet the nutritional needs of residents in accordance with established national guidelines.
2. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance.
3. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods comparable in nutritive value.
5. Menus shall reflect input from residents and resident groups.
a. Resident preferences, including likes and dislikes will be documented in the resident's chart, and shall be reviewed when planning menus.
i. Alternatives shall be immediately available if the primary menu or selections for a particular meal are not to a resident's liking.
ii. Each resident's plan of care will reflect interventions to accommodate nutritional needs when his/her preferences exclude a food group.
1. Review of the facility lunch menu for 12/9/21 showed the following:
- Bacon wrapped beef
- Roasted red skin potatoes
- Fried cabbage
- Peanut butter brownie
- Dinner roll
- Beverages
Observation on 12/9/21 at 11:45 A.M., showed [NAME] B served up the pureed foods. He/she plated the pureed meat and potatoes and covered those with gravy. He/she handed the plate to the dietary staff who set it on the resident's tray. He/she also put a bowl of chocolate pudding on the resident's tray. [NAME] B did not serve any fried cabbage.
Observation on 12/9/21 at 12:15 P.M. showed residents with a pureed diet in the main dining room and none of the plates had fried cabbage. There was not a substitute vegetable provided.
Observation on 12/9/21 at 12:45 P.M. showed a test tray provided to surveyors contained the meat, potatoes, and pureed cabbage.
During an interview on 12/9/21 at 1:10 P.M. the Dietary Manager (DM) said staff forgot to prepare the pureed fried cabbage. He/she realized the cabbage was not prepared for the residents but he/she fixed some for the surveyors' test tray. He/she expected dietary staff to follow the menus for residents who required a pureed diet. Staff should have prepared the cabbage for the residents.
During an interview on 12/10/21 at 11:00 A.M., the Registered Dietician (RD) said he expected dietary staff to follow the menus for all diets. [NAME] B should have served all components of the menu for residents who required a pureed diet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure each resident received foods prepared in a way to conserve nutritive value, flavor and appearance and failed to serve foods that are a...
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Based on observation and interview, the facility failed to ensure each resident received foods prepared in a way to conserve nutritive value, flavor and appearance and failed to serve foods that are a safe and appetizing temperature. The facility census was 104.
Review of the facility's Record of Food Temperatures policy, dated 11/1/21, showed:
-It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled.
-Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens such as bacterial or viral organisms capable of causing disease.
1. Food temperatures will be checked on all items prepared in the dietary department.
2. Hot food will be held at 135 degrees Fahrenheit or greater.
3. Hot foods will be stirred during holding to redistribute heat throughout the food product.
4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit.
Review of the Food Service Inspection, dated 10/7/21, showed:
- Food Preparation: Food quality (plate appearance and taste) good: non-compliant;
- Meal Service: Hot food covered with film or foil: non-compliant;
- Comments: Pureed fish very bland.
- Signed by the Registered Dietitian.
Review of the Resident Council minutes, dated 10/21/21, showed:
- Five residents attended the meeting;
- Old business included residents wanting dinner at a reasonable time and before 7:00 P.M., residents said food arrived cold, and the orders were wrong; Staff did not identify the staff person responsible or what the outcome was;
- New business included residents saying they are not getting the meals they ordered.
Review of the Resident Council minutes, dated 11/30/21, showed:
- Nine residents in attendance;
- No old business, the follow up, or staff person responsible documented;
- New business included food preferences and taste/spices of the food; meals were late, not being passed out timely for hall trays.
1. Observation of the kitchen on 12/14/21 at 10:44 AM showed:
-Food for the lunch meal, including the pureed meals, was already prepared and being kept warm in pans in the oven.
-Dietary Manager took temperatures of the lunch meal on the steam table. The temperatures were as follows:
Turkey and gravy: 143.8 degrees Fahrenheit
Peas: 186 degrees Fahrenheit
Sweet Potatoes: 167 degrees Fahrenheit
Gravy: 182 degrees Fahrenheit
Pureed Sweet potatoes: 160 degrees Fahrenheit
Pureed turkey: 171 degrees Fahrenheit
Pureed peas: 183 degrees Fahrenheit
Observation of the lunch meal on 12/14/21 at 1:22 PM showed:
-The last tray was taken from the tray cart on Maple hall;
-Temperatures of the pureed meal were as follows:
Pureed turkey with gravy: 125.1 degrees Fahrenheit;
Pureed Sweet Potatoes: 118 degrees Fahrenheit.
Observation showed the pureed turkey and gravy was grainy with small particles of turkey, the size of a tic-tac, the pureed peas were full of pieces of skin of the peas, the pureed baked sweet potato was not fully baked and had pieces of potato the size of a tic-tac that required chewing.
Temperatures of the regular meal were as follows:
Turkey with gravy: 126.6 degrees Fahrenheit;
Peas: 103.1 degrees Fahrenheit;
Sweet Potatoes: 127.4 degrees Fahrenheit.
Observation showed the turkey in the gravy was stringy, the baked sweet potato was not fully cooked and bland, and the chocolate chip cookie served with the meal was under-baked and very doughy.
2. Observation on 12/9/21 at 12:45 P.M. showed a test tray served to the survey staff. The plate contained pureed meat, potatoes with gravy and cabbage. The pureed meat and potatoes had some flavor but needed some seasoning. The pureed cabbage was very thin and did not have a good flavor.
During an interview on 12/9/21 at 1:10 P.M., the dietary manager (DM) said he realized the cook forgot to prepare the pureed cabbage for the residents so he made some up for the surveyors. The DM said he does not always taste the pureed foods before they are served to residents.
During an interview on 12/10/21 at 11:00 A.M., the Registered Dietician (RD) said he expected the cooks to taste the pureed food before serving it to the residents. The RD said he did not know where dietary staff kept the temperature log book. He did not remember seeing a temperature log book at this facility.
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 observation, interview, and record review, the facility failed to ensure the pureed food was prepared to a smooth consistency and was palatable. This had the potential to affect all residents...
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Based on observation, interview, and record review, the facility failed to ensure the pureed food was prepared to a smooth consistency and was palatable. This had the potential to affect all residents in the facility on a pureed diet (a texture-modified diet in which all foods have a soft, pudding-like consistency). The facility census was 104.
A review of the facility's Therapeutic Diet Orders policy, dated 11/1/21, showed:
-The facility provides all residents with foods in the appropriate form and/or the appropriate content as prescribed by a physician and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.
-Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids.
1. Each resident's nutritional status is assessed by the interdisciplinary team in accordance with assessment policies.
2. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to:
a. inadequate nutrition
b. nutritional deficits
c. weight loss
d. medical conditions such as diabetes, renal disease, or heart disease
e. swallowing difficulty
4. The reason for a therapeutic diet is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures.
5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.
1. Observation of the lunch meal on 12/14/21 at 1:22 P.M., showed:
-The pureed turkey and gravy was grainy with small particles of turkey, the size of a tic-tac.
-The pureed peas were full of pieces of skin of the peas.
-The pureed baked sweet potato was not fully baked and had pieces of potato the size of a tic-tac that required chewing.
2. Review of Resident #52's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/8/21, showed:
- A Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment;
- Limited staff assistance with eating;
- Diagnoses included Alzheimer's disease, stroke, Parkinson's disease, malnutrition, dysphagia (swallowing problems occurring in the mouth and/or the throat), and a Stage IV (full thickness loss with exposed bone, tendon or muscle. Slough or eschar [dead skin] may be present on some parts of the wound bed. Often includes undermining) pressure ulcer;
- Staff assessed the resident as not having any signs or symptoms of possible swallowing disorder such as loss of liquids/solid foods from mouth when eating or drinking, holding food in cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications); weight documented as 78 pounds.
Review of the resident's current care plan, printed on 12/21/21, showed a focus area of a potential nutritional problem due to dysphagia, Parkinson's disease, stroke, history of malnutrition, and poor appetite with the following interventions:
- Monitor/document/report as needed any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals.
- Provide and serve diet as ordered: Puree with Nectar thick liquids (liquids have slightly more body than thin liquids, but still can pour easily).
Review of the resident's current physician's order sheet (POS), printed on 12/22/21, showed:
- Regular diet, pureed texture; regular thin consistency with nectar thick liquids with a start date of 11/22/21.
Observation on 12/16/21 at 1:00 P.M., showed the resident in the dining room feeding him/herself. On his/her plate the food appeared as ground meat with large chunks and gravy on it. The mashed potatoes sat in a formed ball on his/her plate and appeared very thick and sticky. The resident had thick green pureed vegetables with strings in it and no pureed desert.
3. During an interview on 12/14/21 at 2:15 P.M., the [NAME] said:
-The pureed food should be smooth with no lumps, like baby food.
-There are recipes to follow, but he/she usually goes by how the food looks and adds more liquid if needed.
During an interview on 12/14/21 at 2:21 P. M., the Dietary Manager said:
-The pureed food should be a smooth texture, without lumps.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
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 residents are allowed to make meal choices. Thi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents are allowed to make meal choices. This affected two sampled residents (Resident #46 and #86). The facility census was 104.
Review of the facility's Menus and Adequate Nutrition policy, dated 11/1/21, showed:
-The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines.
-1. The facility will ensure that menus meet the nutritional needs of residents in accordance with established national guidelines.
2. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance.
3. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods comparable nutritive value.
5. Menus shall reflect input from residents and resident groups.
a. Resident preferences, including likes and dislikes will be documented in the resident's chart, and shall be reviewed when planning menus.
i. Alternatives shall be immediately available if the primary menu or selections for a particular meal are not to a resident's liking.
ii. Each resident's plan of care will reflect interventions to accommodate nutritional needs when his/her preferences exclude a food group.
Review of the Resident Self Determination and Participation policy, dated 11/1/21, showed:
-1. A resident's right to self-determination includes, but is not limited to:
a. The right to choose activities, schedules, health care, and providers of health care services consistent with his or her interests, assessments, and plan of care.
b. The right to make choices about aspects of his or her life in the facility that are significant to the resident.
Review of the facility's Resident Council minutes showed:
- 9/16/21: Old business- dietary - trays are late, tickets not being followed; New business included residents stating they cannot read the dietary tickets. Action taken, talked to dietary manager (DM) ;
- 10/21/21: Old business- dietary - want to have dinner at a reasonable time, before 7:00 P.M., food is cold, orders are wrong. New business: residents not getting food they ordered. No action taken listed out beside this entry.
- 11/30/21: No old business listed on the form. New business included: dietary not honoring food preferences, meals are late, menus are not being handed out.
- None of the forms indicated what follow up was done and how these issues had been addressed by dietary.
1. Review of the undated facility Menu Alternates list posted in the dining room showed:
-Lunch and supper choices included hamburger, cheeseburger, hot dog, grilled cheese, deli sandwich, or peanut butter and jelly.
During an interview on 12/13/21 at 1:37 P.M., Resident #46 said:
-He/she eats in his/her room and has still not received the lunch meal.
-He/she never gets a menu to see what the meal for the day is.
-He/she tells the aides he/she wants an alternate for lunch or dinner, like a hamburger or grilled cheese, but always gets served whatever the meal is.
2. Review of Resident #86's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/21 showed:
-BIMS of 11, which shows some difficulty with new situations;
-Independent with cares;
-Diagnoses of seizure disorder, bipolar (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks).
Observation on 12/16/21 at 12:35 P.M. showed:
-The resident was served a hamburger patty covered with gravy, scalloped potatoes, mixed vegetables and fruit cocktail;
-The resident ate 25% of the meal, he/she did not eat the mixed vegetables, and ate a few bites of the hamburger patty and a few bites of the scalloped potatoes.
During an interview on 12/16/21 at 12:35 P.M. the resident said:
-He/she does not like vegetables, he/she does not get a choice of foods at meal times;
-He/she does not like beans but will eat corn;
-No one has talked with him/her about what food he/she likes or dislikes.
Review of the medical records showed no dietary assessment for the resident's food preferences.
3. Review of Resident #42's admission MDS, dated [DATE], showed:
- BIMS score of 15 indicating the resident had no cognitive impairments;
- Diagnoses included non-pressure chronic ulcer, high cholesterol, body mass index (BMI) of 40.0 to 44.9 (morbid obesity), and diabetes mellitus.
During an interview on 12/15/21 at 10:18 A.M., the resident said the food is not good. It is cold, and just does not taste good. Meals are always late. He/she is very picky. After he/she was admitted , they had a care plan meeting where they talked about his/her food preferences. The DM indicated he would take care of the resident regarding food choices, but he has not followed through. The resident really likes grilled chicken and the DM said he would always have it but the cooks will tell him/her they do not have it. The snacks are not good. There is no fruit and if you want to have a snack, it is all junk food. The resident has diabetes and he/she is trying to make healthier snack choices to heal his/her foot wound, but the facility does not help with that.
Observations on all days of the survey on 12/9/21, 12/10/21, 12/13/21 through 12/17/21 and 12/20/21 through 12/22/21, showed staff did not provide grilled chicken to the resident. He/she ordered food from local restaurants to be delivered because he/she did not like the choices on some days of the survey.
4. During an interview on 12/10/21 at 2:30 P.M., the dietary manager said residents are able to make requests for certain foods. They try honor each resident's food preferences. They have some residents who make specific choices and he tries to keep those foods on hand for staff to fix for them.
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 interview and record review, the facility failed to maintain an infection prevention and control program designed to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when staff failed to administer the Two-Step Tuberculin (TB) test appropriately, read, and document the results of the test in a timely manner for three sampled residents (Resident #66, #84 and #86). The facility census was 104.
The facility did not provide a policy for TB testing.
1. Review of Resident #66's medical record on 12/17/21 at 12:15 P.M., showed:
-The resident was admitted on [DATE]. The record showed no documentation of any TB tests given.
2. Review of #84's medical record on 12/17/21 at 12:25 P.M., showed:
-The resident was admitted to the facility on [DATE].
-TB first step Mantoux (a test for immunity to tuberculosis using intradermal injection of tuberculin.) test given on 5/17/21 with a negative reading. No documentation of a second TB test given.
3. Review of Resident #86's medical record on 12/17/21 at 12:30 P.M., showed:
-The resident was admitted to the facility on [DATE], documented TB 1 step Mantoux given with negative results on 5/3/21. No documentation of the TB 2 step Mantoux.
4. During an interview on 12/20/21 at 2:00 P.M., the interim Director of Nursing (DON) and Administrator said:
-A log with all of the residents was usually kept in the DON's office, but they cannot find the book.
-Residents should receive a two step TB test upon admission and two to three weeks after the initial TB tests.
-This should be documented in the resident's medical record and a log should be kept.
During an interview on 12/22/21 at 4:22 P.M., the administrator said the interim DON was supposed to get the testing form and fill in the lot number. Staff are supposed to keep a TB log and this should also be in the DON's office and it is no longer there.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all residents were offered influenza, pneumonia and COVID-19...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all residents were offered influenza, pneumonia and COVID-19 vaccinations in a timely manner. This affected six sampled residents (Residents #28, #59, #66, #84, #86 and #98) out of 24 sampled residents. The facility census was 104.
Review of the facility policy for Infection Prevention and Control Program, date implemented 11/1/21, showed:
-Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
-Influenza and Pneumococcal Immunizations:
a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or the resident received the vaccine elsewhere during that time;
b. Residents will be offered the pneumococcal vaccines recommenced by the Centers for Disease Control and Prevention (CDC) upon admission, unless contraindicated or received elsewhere;
c. Education will be provided to the resident and/or representative regarding the benefits and potential side effects of the immunizations prior to offering the vaccines;
d. Residents will have the opportunity to refuse the immunizations;
e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations.
-COVID-19 (an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions):
a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility;
b. Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions and contraindications to determine candidacy for the vaccination;
c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine;
d. Residents or resident representative and staff will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision;
e. Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine.
1. Review of Resident #84's medical record on 12/17/21 at 12:25 P.M., showed:
-The resident was admitted to the facility on [DATE]. No documentation the influenza or pneumonia vaccines were offered or given;
-A history of only one dose of the COVID-19 vaccine documented as received on 5/20/21;
-No documentation of offering the COVID-19 vaccine.
2. Review of Resident #86's medical record on 12/17/21 at 12:30 P.M., showed:
-The resident was admitted to the facility on [DATE]. No documentation the influenza or pneumonia vaccines were offered or given.
3. Review of Resident #66's medical record on 12/17/21 at 12:40 P.M., showed:
-The resident was admitted to the facility on [DATE]. No documentation the influenza or pneumonia vaccines were offered or given.
4. Review of Resident #28's medical record on 12/17/21 at 12:45 P.M., showed:
-The resident was admitted to the facility on [DATE];
-There was no documentation the COVID-19 vaccine was offered or given;
-There was no documentation the influenza or pneumonia vaccines were offered or given.
5. Review of Resident #98's medical record on 12/17/21 at 12:50 P.M., showed:
-The resident was admitted to the facility on [DATE];
-There was no documentation the COVID-19 vaccine was given or offered;
-No documentation the influenza or pneumonia vaccines were offered or given.
6. Review of Resident #59's medical record on 12/17/21 at 12:55 P.M., showed:
-The resident was admitted to the facility on [DATE]. No documentation the pneumonia vaccine was offered or given.
During an interview on 12/22/21 at 4:22 P.M. , the Director of Nursing and Corporate Nurse B said:
-The Influenza and pneumonia vaccination program is the responsibility of the Director of Nursing (DON);
-He/she just started at the facility and cannot find any documentation from the prior DON;
-A corporate nurse is working on the program;
-The facility should have started the flu program and ensured that the residents were offered the COVID-19 vaccination and the pneumococcal vaccine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to maintain non-resident use areas in good, safe, sanitary conditions. The facility also failed to maintain the sidewalk and driveway, potential...
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Based on observation and interview, the facility failed to maintain non-resident use areas in good, safe, sanitary conditions. The facility also failed to maintain the sidewalk and driveway, potentially causing a tripping hazard. The facility census was 104.
1. Observation on 12/21/21 and 12/22/21 at various times, showed the following:
- Basketball sized area on the ceiling with damaged drywall in the Restorative Therapy office;
- In the laundry room, there was a three 2 inch () by 3 wood board being used to hold up a section of the ceiling;
- In the employee lounge in the A hall, there were six broken floor tiles, the vanity was cracked and pulling away from the wall;
- The B hall employee lounge had several areas up to golf ball size where the yellow painted ceiling was peeling;
- The font receptionist office/copier area had 1 foot (') of baseboard peeling away from the wall in the back corner;
- In the upstairs area there was a watermelon sized brown stain on the ceiling at the top of the stairs.
- In the business office there was a beach ball sized area on the ceiling that had been patched, but had not been refinished to match the rest of the ceiling, there was also another four foot by four foot area on the ceiling that had been patched and not refinished. There was also a dusty vent.
- In the computer room there was a beach ball sized brown stain on the ceiling;
- D hall water heater room had a watermelon sized unfinished patch on the ceiling;
- D hall employee restroom there was a brown, peeling area on the wall where a soap dispenser was torn off the wall;
- The E hall employee restroom's ceiling was cracked the entire width of the room;
- The E hall clean utility room had a large area on the ceiling that was stained brown and a 4' by 8' area on the ceiling that was unfinished;
- The E hall soiled utility room had a 3' by 6' area on the ceiling that was unfinished;
- The E hall clean linen closet had a beach ball sized stain on the ceiling;
- The E hall water heater room had a beach ball sized stain on the ceiling and a 12 by 12 unfinished patch on the ceiling;
- There was a 1 by ½ hole in the wall in the memory care unit manager's office;
- The entire ceiling in the dry food storage area in the kitchen was unfinished which included gaps up to 1/4 inch around the edge of the ceiling and a 1 1/2 by 2 1/2 gap in the ceiling;
- The service hall door separating the service hall from the front entrance area had multiple gouges in the door, up to ½' by 2, the entire length of the door edge.
2. Observation and interview on 12/22/21 beginning at 10:50 A.M., showed the North side driveway had several large potholes up to 10' longer and up to 6 deep. The Maintenance Director said he had noticed the large pot holes in the drive as well.
3. During an interview on 12/22/21 beginning at 3:10 P.M., the Maintenance Director said:
- Each nurse station had a maintenance request book. The books were checked twice per day, once in the morning and once before he left for the day;
- He had noticed the maintenance needs that were in the facility since he started in November. He tried to take care of what he could and made mental notes of the other things that needed addressed;
- He knew there were issues with the ceiling and tiles;
- He had not received any complaints from residents or family members regarding the condition of the facility.
During an interview on 12/22/21 at 3:50 P.M., the Administrator said:
- She had not received any complaints from residents or family regarding the condition of the facility;
- She was not aware of the condition of the facility until the state surveyors came to the facility because she had been working in therapy, she just recently became the Administrator.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to maintain a safe, clean and comfortable homelike environment. This had the potential to affect all residents. The facility census was 104.
1. ...
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Based on observation and interview, the facility failed to maintain a safe, clean and comfortable homelike environment. This had the potential to affect all residents. The facility census was 104.
1. Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/11/21, showed:
- A Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment.
During an interview on 12/14/21 at 4:30 P.M., Resident #42 said:
- Have you seen the facility? They do not keep it clean around here. It seems like housekeeping does not always do what they need to do to keep it clean. They will mop and the floors are still dirty and sticky. Shouldn't the staff want to keep this place cleaner? He/she has seen the housekeeping staff just wandering up and down the halls with their carts, but not going into rooms. They have had issues with ants on Maple. He/she has seen them in his/her room and in the hallway by the nurses' station. The nurse used a can of bug spray to kill them, which it did, but the dead ants laid on the floor for several days, because no one swept the floors in the hallway.
Observation on 12/15/21 at 10:15 A.M. showed a can of bug spray on the floor behind the nurses' station.
Observation on 12/14/21 at 9:33 A.M. showed in the employee restroom between service hall and [NAME] veneer peeling off the doors, the counter top coming away from the wall, and the sink with porcelain missing and not cleanable. The housekeeper walked down the hall with spray and a rag, but not cleaning consistently. He/she wiped small sections of railings as he/she walked, but not the entire railing.
Observation on 12/21/21 and 12/22/21, at various times, showed the following observations in the following rooms:
- #A-3- Multiple holes of various sizes that had been filled and not repainted;
- # A-4- Multiple patches on the wall that were not repainted, four brown stains about the size of a half dollar on the ceiling;
- #A- 8- 6 inch () by 36 area where the drywall seam was bubbling up and separating from the drywall;
- The kitchenette on the A hall had a large area of popcorn ceiling texture peeling away from the ceiling;
- #A-15-the toilet was missing the lid to the tank;
- #A-16-a brown colored substance around the base of the toilet;
- #A-18- a baseball sized unpainted patch on the wall;
- #A-19- the packaged terminal air conditioner (PTAC) had a build up of dust and debris on the vent as well as a dried liquid that looked like a drink or food had been spilled on it;
- #A-22-dust caked on the PTAC and 8 of baseboard missing in the room;
- # A-25- 2 inch by 4 hole in the wall by the base board;
- # A-23- a basketball sized unpainted patch on the wall;
- Multiple patches of various sizes, up to the size of an orange, on the wall in the A hallways that had not been repainted;
- #B-1- a brown colored substance around the base of the toilet;
- #B-2- a basketball sized patch on the wall that was unpainted;
- #B-4- a vent in the bathroom contained dust and debris;
- #B-5- two baseball sized unpainted patches on wall;
- #B-8- the PTAC vent contained dust and debris and the vent was cracked;
- #B-9- three large patches on the ceiling approximately 4' by 6' that was unfinished;
- #B-10- a basketball sized brown stain over the bed
- #B-18- multiple baseball sized patches that were unfinished on the walls;
- #B-20- a black substance around the base of the toilet;
- #B-22- a basketball sized brown stain on the ceiling. The vent in the room contained dust and debris;
- #B-25- the PTAC had a build up of dust and debris on the vent;
- B Hall Shower room- 20 of the ceiling seams were separating from the drywall. Multiple areas the ceiling was peeling;
- The front main dining area showed three vents had dust and debris on them and on the ceiling around the vents. The large intake vent was caked with dust and debris;
-#C-18- Central Bath- 4' seam of the ceiling was separating from the ceiling and was cracked. There was also a black substance on the vent;
- #D-1- multiple patches, up to baseball sized, on the wall that were unfinished;
- #D-3- cracked and broken flooring in the bathroom;
- #D-4- golf ball sized hole in the wall along the back corner;
- #D-7- multiple unfinished patches on the wall of various sizes;
- #D-8- multiple unfinished patches on the wall of various sizes up to a baseball sized;
- #D-19- a cantaloupe sized brown stain on the ceiling in the bathroom;
- #D-21- four patches unfinished patches, up to the size of a watermelon, on the wall;
- #D-25- 12 by 12 area on the ceiling that was unfinished in the bathroom, the PTAC cover was cracked, and multiple patches of various sizes up to baseball sized were unfinished on the wall, there were also two broken tiles on the floor;
- #D-27- five dime sized holes in the wall, the cinderblock window sill and a 1/8 by 2 crack. The PTAC had dust and debris on the vent;
- D- hall shower room-PTAC cover was broken;
- D Hall Central Bath- a black substance on the vent and a black substance on the PTAC vent;
- #D Hall dining room- four unfinished patches;
- #E-1- a beach ball sized brown substance dried to the floor next to the bed, brown substance around the base of the toilet, black substance on the PTAC vent, brown staining under the sink, several gouges on the door of various sizes from the bottom of the door to 16 up the door;
- #E-2- a brown discoloration on the floor under the sink;
- #E-3- PTAC cover and knob was broken, brown substance around the base of the toilet;
- #E-4- the door had several gouges on the edge of the door from the bottom to about 12 up the door, the bathroom ceiling had a 6' crack running across it, 5' of the baseboard in the room was missing, and a 4' by 4' area on the ceiling was pealing;
- #E-5- Central bath- up to a ½ gap in the wall around the shower fixture, a light was missing its cover, 5 of the tile base trim was separated from the wall, the PTAC contained dust and debris
- #E-6- two broken tiles along the back wall, the bathroom had a 5 by 4 patch on the wall along the floor, multiple unfinished patches were on the wall;
- #E-7- three baseball sized, unfinished patches on the wall;
- #E-8- the ceiling had a 3' by 4' that was unfinished, and a 4 by 4 area in the bathroom that was unfinished;
- #E-9- PTAC vent contained dust and debris, basketball sized area on the wall where paint was chipping, several small brown spots on the wall;
- #E-11- the baseboard behind the toilet was missing, 4' on each side of the bathroom wall had been patched and unfinished, under the sink there was brown staining on the wall and the floor;
- #E-12- a brown substance around the base of the toilet;
- #E-20- a hole in the wall behind the door where the doorknob had damaged the wall, ¼ gap in the wall around the water line entering the room;
- E Hallway- vent contained dust and debris, the hallway also had a 3' by 14 area where the wall paper was peeling;
- #E- 23-Hall Central Bath- shower head was mounted to a hand rail with a rusty wire clothes hanger, two baseball sized unfinished patches on the wall; and the door was damaged with several gouges of various sizes along the entire length of the door;
- #E-25- 6' by 3' ceiling damaged and the ceiling around the light had a brown stain on it and there were four broken floor tiles;
- #E-26- a watermelon sized blue stain on the floor;
- #E-27- a beach ball sized patch on the wall that was unfinished, next to the bed there was a 1 ½ by 16 unfinished patch on the wall, and a brown substance was smeared on the wall;
- The Memory Care Unit dining room had a basketball sized stain on the ceiling, a 3' by 3' unfinished area on the ceiling and a 3' area on the ceiling where a seam was separating from the drywall;
- 4' by 8' area on the ceiling outside of the therapy gym where the popcorn texture was peeling .
During an interview on 12/22/21 beginning at 3:10 P.M. the Maintenance Director said:
- Each nurse station had a maintenance request book. The books were checked twice per day, once in the morning and once before he left for the day;
- He had noticed the maintenance needs that were in the facility since he started in November. He tried to take care of what he could and made mental notes of the other things that needed addressed;
- A metal clothes hanger used to hang a shower head from an assist bar was not acceptable;
- He knew there were issues with the ceiling and tiles;
- He had not received any complaints from residents or family members regarding the condition of the facility.
During an interview on 12/22/21 at 3:50 P.M. the Administrator said:
- She had not received any complaints from residents or family regarding the condition of the facility;
- The facility should be kept in a homelike condition;
- She was not aware of the condition of the facility until the state surveyors came to the facility because she had been working in therapy, she just recently became the Administrator.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure there was an adequate number of staff to perfor...
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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 there was an adequate number of staff to perform duties to enhance the residents' quality of life. Restorative nursing staff were pulled to work as nurses aides, and were unable to complete duties for the restorative therapy nursing program for three residents (Resident #12, #53 and #84); staff failed to provide assistance with activities of daily living (ADLs), including dressing, bathing and personal hygiene, to dependent residents for five sampled residents (Residents #11, #54, #68, #71 and #98); and the facility failed to provide adequate staff for wound and pressure ulcer (PU) care for 2 sampled residents (Resident #84 and #254) out of 24 sampled residents. The facility census was 104.
Review of the facility policy for Restorative Nursing Programs, dated 11/1/21, showed:
-It is the policy of this facility to provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable levels;
-Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning;
-Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy;
-The Restorative Nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented;
-A resident's Restorative Nursing plan will include: the problem, need, or strength the restorative tasks are to address; the type of activities to be performed; frequency of activities; duration of activities; measurable goal and target date;
-The discharging therapist, Restorative Nurse, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan;
-Restorative aides will implement the plan for the designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form;
-The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly.
1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/7/21, showed staff documented the resident as:
-Severely cognitively impaired;
-Required supervision with Activities of Daily Living (ADLs);
-Received occupational and physical therapy;
-Did not receive restorative nursing services.
Review of the resident's Therapy Communication to Restorative Nursing Program, dated 10/12/21, showed:
-Referred by Physical Therapy to Restorative Nursing;
-Current Functional Status: stand by assistance (SBA) with verbal cues;
-Problems/needs: maintain ambulation status;
-Goals of Intervention: Maintain independence and strength;
-Recommendations/approaches: seated therex (Therapeutic Exercise & Activity - TherEx & TherAc are the systematic and planned performance of body movements or exercises which aim to improve and restore function) if tolerates with three pound weights and walking forward;
-Precautions: occasional stumbling/difficulty with obstacles;
-Assistance Required: stand by assistance (SBA)/contact guard assistance (CGA).
Review of the resident's medical record showed no documentation the resident received Restorative Nursing services and no care plan for the program.
2. Review of Resident #53's comprehensive MDS, dated [DATE], showed staff documented the resident as:
-Severely cognitively impaired;
-Required extensive assistance of one person with ADLs.
Review of the resident's Therapy Communication to Restorative Nursing Program, dated 12/13/21, showed:
-Referred by Physical therapy;
-Current Function Status: varies on resident participation, minimum to maximum assistance;
-Problems/needs: weakness and instability;
-Goad of Intervention: maintain functional mobility;
-Recommendations/Approaches: complete both lower extremities (BLE) exercises with 25 pound weights and complete sit to stand transfers;
-Precautions: aggressive, agitation, poor positioning and retro lean (loses balance and falls backwards);
-Assistance Required: minimum to maximum assistance.
Review of the resident's medical record showed no documentation the resident received Restorative Nursing services and no care plan for the program.
3. Review of Resident #84's Therapy Communication to Restorative Nursing Program, dated 10/26/21, showed:
-Current functional status: hand held assistance (HHA) for directional cues;
-Problems/needs: decreased balance and safety awareness;
-Goals of Intervention: maintain functional mobility;
-Recommendations/approaches: use HHA to ambulate with resident;
-Precautions: poor cognition, fall risk;
-Assistance required - HHA.
Review of the quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Required extensive assistance for ADLs', limited assistance for walking and locomotion;
-Did not receive Restorative Nursing services.
Review of the resident's medical record showed no documentation the resident received Restorative Nursing services or a care plan for Restorative Nursing.
During an interview on 12/16/21 at 10:06 A.M., Restorative Aide (RA) A said:
-He/she is the Restorative Aide;
He/she does the monthly weights and now he/she does the showers for the entire building;
-He/she has not had a chance to do Restorative Nursing for several months due to being pulled to the floor to work as a Certified Nurse Aide (CNA) and to do showers.
During an interview on 12/22/21 at 3:52 P.M. the MDS Coordinator said:
-She has not been writing any Restorative Nursing care plans due to not having a Restorative Aide. The Restorative Aide has been pulled to work the floor as the shower aide and a CNA;
-Restorative Nursing has not been done.
4. Review of the facility's policy on Activities of Daily Living (ADLs), dated 11/1/21, showed:
-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.
-Care and services will be provided for the following activities of daily living:
1. Bathing, dressing, grooming, and oral care;
2. Transfer and ambulation;
3. Toileting;
4. Eating to include meals and snacks; and
5. Using speech, language, or other functional communication systems.
-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
The facility was unable to provide shower sheets.
5. Review of Resident #71's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required extensive to total assistance with ADLs, including dressing, bed mobility and bathing.
Review of the resident's care plan, dated 11/3/21, showed:
-He/she prefers to bathe/shower 2-3 times per week, washing hair during bath/shower;
-Requires assistance of 2 staff with bathing/showering twice weekly and as needed, using a mechanical lift;
-Requires a mechanical lift with 2 staff assistance for transfers, uses wheelchair and propels self.
Observation on 12/14/21 at 9:32 A.M., showed:
- The resident lying in bed in hospital gown, gown dirty with stains on front. The resident's hair appears greasy and unkempt.
During an interview on 12/14/21 at 9:32 A.M., the resident said:
-He/she is unable to get out of bed as there is not a lift in the facility that can handle his/her weight;
-He/she has not been out of bed since August;
-He/she is supposed to get bed baths, but it doesn't happen because there isn't enough staff.
6. Review of Resident #68's admission MDS, dated [DATE], showed staff assessed the resident as:
- Severely cognitively impaired;
-No behaviors noted;
-Required extensive assistance from staff for all activities of daily living.
Review of the resident's care plan, dated 11/15/21, showed:
-The resident has an ADLs self-care performance deficit related to/ dementia;
-The resident will receive appropriate support from staff with ADLs through next review date;
-Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse;
-The resident requires assistance by one staff with showering twice weekly and as necessary;
-The resident requires assistance by one staff to turn and reposition in bed;
-Resident requires assistance by one staff to dress;
-Resident requires assistance by one staff for personal hygiene and oral care;
-Resident requires assistance by one staff for toileting/incontinence care.
Observation of Resident #68 on 12/14/21 at 2:48 P.M., showed:
-The resident wheeled his/herself down the hallway in a wheelchair;
-He/she was dressed in pants and long sleeve shirt. The shirt was dirty with stains and food matter;
-His/her hair was unkempt and appeared greasy.
Observation on 12/15/21 at 10:45 A.M., showed:
-The resident wore the same clothing from the day before. The shirt continued to be dirty with stains and food matter.
-His/her hair continued to be unkempt and appeared greasy.
7. Review of Resident #54's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-No behaviors noted;
-The resident requires limited to extensive assistance with activities of daily living.
Review of the resident's care plan, dated 10/22/21, showed:
-The resident's desired personal care routine was showering in the afternoon, twice weekly, staff to assist with shaving on shower days, washing hair with showers;
-The resident had an ADLs self-care performance deficit related to Parkinson's disease;
-Check nail length and trim and clean on bath day and as necessary. Report changes to the nurse;
-Required assistance of one staff with showering;
-Provide sponge bath when full bath or shower cannot be tolerated;
-Allow sufficient time for dressing and undressing;
-Required assistance with one staff for dressing;
-Required assistance of one staff for personal hygiene and oral care;
-Required assistance of one staff for incontinent care.
Observation on 12/14/21 at 9:16 A.M., showed:
-The resident had significant facial hair grown, at least a half inch;
-His/her nails were long and had dark matter underneath;
-The resident's hair was unkempt and appeared greasy.
During an interview on 12/14/21 at 9:16 A.M., the resident said:
-There is not enough staff to shave and shower the residents;
-He/she cannot remember the last time he/she had a shower;
-He/she would like to be shaved at least every other day, and he/she does not like to have long facial hair;
-He/she would also like to have his/her nails clipped. He/she likes them kept short.
8. Review of Resident #11's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-No behaviors noted;
-Required extensive assistance with ADLs.
Review of the resident's care plan, dated 12/14/21, showed:
-The resident's desired personal care routine is showering twice weekly, independent with shaving, washing hair, and with showering;
-The resident had an ADLs self-care performance deficit related to congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should) and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of his/her lower extremities;
-Dependent on 1-2 staff to provide bath/shower twice weekly and as necessary;
-Provide sponge bath when a full bath or shower cannot be tolerated;
-Required assistance of 1-2 staff to turn and reposition in bed;
-Required assistance of 1-2 staff to dress;
-Required assistance of 1-2 staff with personal hygiene and oral care;
-Dependent on 2 staff for incontinent cares;
-Required mechanical lift with 2 staff assistance for transfers.
Observation on 12/13/21 at 2:25 P.M., showed:
-Resident lying in bed, wearing a hospital gown;
-Gown was dirty with stains and food matter;
-Hair was unkempt and appeared greasy;
-The resident had facial hair growth of approximately a quarter of an inch.
During an interview on 12/13/21 at 2:25 P.M., the resident said:
-He/she rarely gets out of bed because there are never enough staff to use the mechanical lift, as it requires 2 staff at a time;
-He/she cannot use the bathroom in his room because he/she needs a lift to get out of bed, and the bathroom and bathroom door are too small to accommodate the resident's electric wheelchair. He/she has to use the bed pan but would prefer to use the toilet;
-He/she is supposed to get two showers per week, on Tuesdays and Fridays. Since September, he/she feels they are lucky to get one shower per week;
-There are no staff specifically assigned to showers;
-He/she has skin issues and needs to shower frequently to prevent skin break down.
9. Review of Resident #98's comprehensive MDS, dated [DATE], showed staff assessed the resident as:
-Unable to answer questions;
-Required supervision with ADLs;
-Required extensive assistance with toileting.
Review of the undated care plan for self-care performance showed:
-Focus: the resident has an ADLs self-care performance deficit related to Alzheimer's disease;
-Goal: The resident will receive appropriate support from staff with his/her ADLs;
-Interventions/Tasks: Toilet use: the resident requires assistance by one staff for toileting/incontinence care, encourage the resident to use the call bell for assistance.
Observation on 12/10/21 at 2:20 P.M., showed the resident leaving the dining room with a CNA, the back of the resident's pants was saturated with urine. The CNA walked the resident back to his/her room and stood the resident at the sink and pulled down his/her pants, removed a saturated brief and provided incontinent care;
-The CNA took the resident to the bathroom where the resident had a large bowel movement. The CNA walked the resident to his/her bed and laid him/her down, applied a clean brief.
During an interview on 12/10/21 at 2:30 P.M., Restorative Aide A said:
-The resident is incontinent of urine and needs help;
-He/she is not the resident's aide, he/she is giving showers on the hall;
-He/she is the restorative nursing aide.
During an interview on 12/22/21 at 4:22 P.M., the Director of Nursing and Corporate Nurse B said:
-They would expect the residents to be checked every 2 hours, prior to meals, after meals, activities and upon rounds for toileting needs.
10. Review of the facility policy for Pressure Injury (PI) Prevention and Management, dated 11/1/21, showed:
-This facility is committed to the prevention of avoidable pressure injuries and promotion of healing of existing pressure injuries;
-The facility shall establish and utilize a systematic approach for the PI prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate;
-Assessment of PI risk:
-Licensed nurses will conduct a pressure injury risk assessment, using (fill in blank for designated tool), on all residents upon admission/readmission, weekly times four weeks, then monthly or whenever the resident's condition changes significantly;
-The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: impaired/decreased mobility and decreased functional ability; co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus; exposure of skin to urinary and fecal incontinence; under nutrition, malnutrition, and hydration deficits; and the presence of a previously healed PI;
-Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly and after any newly identified PI. Findings will be documented in the medical record;
-Assessments of PI will be performed by a licensed nurse, and documented on the (fill in the black for designated form). The staging of PI will be clearly identified to ensure correct coding on the Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff;
-Monitoring: The Registered Nurse (RN) Unit Manager, or designees, will review all relevant documentation regarding skin assessments, PI risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record;
Review of the facility policy for Wound Treatment management ,dated 11/1/21, showed:
-Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders;
-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change;
-In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse;
-Treatments will be documented on the Treatment Administration Record (TAR);
-The effectiveness of treatments will be monitored through ongoing assessments of the wound.
11. Review of Resident #254's admission skilled nurses notes, dated 4/20/21, showed:
-admission: skin: mottled (lack of blood flow throughout the body);
- Pressure ulcers: feet are discolored with a wound to the left heel. Bilateral feet are scaly and cracked.
Review of the wound assessment, dated 4/20/21, showed:
-Left buttock, Stage 1 (Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it then remove your finger). Area is pink and is resolved.
Review of the resident's care plan for PU, dated 4/21/21, showed:
-Focus: Resident has a pressure ulcer (PU) to the left heel and a left buttock wound;
-Goal: PU will show signs of healing and remain free from infection;
-Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness; administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing with every treatment, measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed and healing process. Report improvements and declines to the physician; educate his/her family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent reposition; follow facility policies/protocols for the prevention/treatment of skin breakdown; low air loss mattress; monitor nutritional status; monitor and document and repot any changes in skin status, appearance, color, wound healing, signs and symptoms of infections, wound size, assistance to turn/reposition at least every two hours, more often as needed or requested; weekly treatment documentation to include measurements of each area of skin breakdown.
Review of the admission MDS, dated [DATE] showed staff assessed the resident as:
-Unable to answer questions;
-Dependent upon staff for Activities of Daily Living (ADLs);
-Incontinent of bowel and bladder;
-Diagnoses of coronary artery disease (CAD), Alzheimer's disease, Parkinson's disease (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination.) and depression;
-At risk for development of pressure ulcers (PU);
-One Stage 1 PU (The skin appears reddened and does not blanch (lose color briefly) and one unstageable PU (Unstageable pressure injury is a term that refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar.).
Review of the medical record showed an order for weekly skin assessments every Tuesday night, dated 4/27/21.
Review of the hospice provider's notes showed no documentation of the resident's skin condition.
During an interview on 12/16/21 at 2:41 P.M., the hospice provider said:
-The resident was admitted to the facility under their hospice care;
-At the time of admission, the facility was not allowing any hospice providers in the facility;
-The hospice was only doing telehealth at this time, due to the COVID-19 pandemic.
Review of the medical record from 8/20/21 through 11/28/21, showed no assessments of the wounds.
During an interview on 12/9/21 at 2:00 P.M., the former Director of Nursing said:
-The facility did not have a wound nurse to complete the weekly wound assessments due to lack of staff;
-He/she had not done any wound assessments.
During an interview on 12/10/21 at 12:42 P.M., LPN D said:
-He/she was promoted to the wound nurse in August 2021, but had not received any training;
-He/she only did wounds one time, then was pulled to the floor to work, and never assessed the wounds again;
-He/she resigned as the wound nurse a few weeks after he/she had been promoted due to not being able to function as the wound nurse;
-The wound nurse does the weekly wound assessments, but since the facility does not have a wound nurse, no assessments have been completed.
During an interview on 12/14/21 at 3:22 P.M., LPN E said:
-Wound assessments are completed by the wound nurse, but the facility does not have a wound nurse, so no wound assessments have been done.
During an interview on 12/14/22 at 3:30 P.M., the former Administrator said:
-The facility was short staffed on nurses and had to pull the wound nurse to work the floor;
-The facility did not have a dedicated wound nurse to complete the wound assessments;
-She would have expected the nurses to complete the wound dressings and complete the wound assessments.
12. Review of Resident #84's care plan for Diabetes Mellitus (DM), dated 5/17/21, showed in part:
-Focus: the resident has DM;
-Goal: the resident will have no complications related to DM through the review date with a revision date of 8/26/21;
-Interventions/task: Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness;
-Monitor/document/report as needed (PRN) any signs and/or symptoms of infection to any open area: redness, pain, heat, swelling or pus formation.
Review of Resident #84's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Unable to answer questions;
-Required extensive assistance of one staff for dressing, transfer, limited assistance of one staff member for walking, locomotion and dependent upon one staff member for personal hygiene;
-Incontinent of bowel and bladder;
-Diagnoses of hypertension (HTN, high blood pressure), diabetes (DM), stroke (Cerebral Vascular Accident (CVA), aphasia (inability to speak due to the CVA), and psychotic disorder (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions.);
-At risk for pressure ulcers and did not have any current PU.
Review of the weekly skin check, dated 11/10/21 and 11/23/21, showed no wounds or open areas.
Review of the medical record showed staff did not document they completed a weekly skin check on 11/17/21.
Review of the resident's bath sheets completed by staff, showed staff did not document on the wounds on 10/29/21, and the resident refused on 11/18/21 showed. The facility was unable to provide any other bath sheets to show the resident received a bath or that nursing staff assessed the resident's skin.
Review of the nurses notes, dated 11/28/21, signed by Licensed Practical Nurse (LPN) B at 4:49 P.M., showed:
-The resident's second toe on the right foot looks black and moist. The right foot looks slightly swollen and red but not warm to the touch. A black spot on the left toe was noted. The resident appears to have pain when providing care to the area. PRN Tylenol administered with effectiveness. Notes faxed to the resident's physician. The Director of Nursing (DON) aware. The family notified.
Review of the nurses notes, dated 11/29/21 at 3:32 P.M., signed by LPN B showed:
-Physician to order Keflex (medication used to treat a wide variety of bacterial infections) 500 milligrams (mg) four times a day (QID) for wound on second toe on the right foot.
Review of the resident's undated care plan for skin showed in part:
-11/29/21: Focus: the right foot second toe is black/moist; black spot on toe on left foot;
-Goal: did not specify a goal for the areas to the feet;
-Interventions/task: 11/29/21: toe cleaned with wound cleanser (WC) and Tylenol given for signs/symptoms of pain while treating area. All parties notified.
Review of the physician's progress note, dated 11/30/21 at 11:42 A.M., signed by Physician A showed:
-Notified by nursing that the resident had digital ulcers of the left foot. Examination of the right foot demonstrates the second toe has circumstantial dry gangrene (this type of gangrene involves dry and shriveled skin that looks brown to purplish blue or black. Dry gangrene may develop slowly. It occurs most commonly in people who have diabetes or blood vessel disease, such as atherosclerosis; is a dangerous and potentially fatal condition that happens when the blood flow to a large area of tissue is cut off. This causes the tissue to break down and die. Gangrene often turns the affected skin a greenish-black color.). Diminished capillary refill and cool, no odor, no discharge, no drainage, duration is unknown, first documentation is 11/28/21. The resident is currently on Plavix ( used to prevent heart attacks and strokes in persons with heart disease (recent heart attack), recent stroke, or blood circulation disease) and Atorvastatin (used to lower cholesterol ) and weekly skin assessments.
Review of the nurses notes, dated 11/30/21 at 12:32 P.M., showed:
-The physician came in to see the resident's toe on his/her right foot. The physician asked for the resident to be sent to the hospital for treatment of the right foot second toe being black. Right foot is edematous (swelling) and mild redness and warm.
Review of the nurses notes, dated 11/30/21 at 10:04 P.M., showed:
-Update on the resident's status at local hospital, the resident was admitted with diagnosis of gangrene.
Review of the hospital admission paperwork, dated 11/30/21, showed:
-Resident has a right foot wound. He/she is currently at nursing home and they noticed his/her right second toe was black two days ago;
-Right second toe appears ischemic (an inadequate blood supply to an organ or part of the body) in nature. Unable to assess pedal pulses (pulses found in the top of the foot);
-X-ray results showed an infection in the second toe on the right foot;
-Diagnosis of gangrene to the second toe on the right foot;
-Resident is not a candidate for surgical interventions at this time. Recommend conservative measures.
Review of the nurses note, dated 12/7/21 at 3:48 P.M., showed:
-The resident readmitted to the facility from local hospital. Spoke with nurse from the local hospital who said the resident had a CT (computed tomography scan - A procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body.) of the second toe of the left foot and no osteomylitis(inflammation of bone or bone marrow, usually due to infection) was found. The resident was not a candidate for surgical amputation. New orders to cleanse with betadine then wrap the toe.
Review of the the weekly skin check, dated 12/8/21, showed:
-Scabs to the left knee. Dry dressing intact on toes on the right foot. Scab from blood blister on the fifth toe to the left foot.
Observation on 12/9/21 at 11:26 A.M., showed:
-The resident lay in bed with his/her right foot wrapped with a Kerlix dressing;
-LPN C removed the dressing to the foot;
-The second toe to the right foot was black in color;
-The resident moaned when the nurse removed the dressing and pulled his/her foot back.
During an interview on 12/9/21 at 11:40 A.M., LPN C said:
-He/she had only worked with the resident a couple of times, he/she does not normally work the hall that the resident resides;
-He/she had not seen the resident's toe prior to this day.
During an interview on 12/9/21 at 1:35 P.M., Certified Nurse Aide (CNA) A said:
-He/she has worked the hall the resident lives on for about a month;
-He/she had noticed the second toe on the right foot was black couple of weeks ago;
-He/she reported this to a nurse, but he/she does not remember which nurse;
-There is no place for CNAs to document when a resident has a skin condition.
During an interview on 12/9/21 at 2:35 P.M., LPN B said:
-He/she frequently works the hall that the resident lives on;
-He/she was the nurse who reported the black area on the second toe on the right foot to the physician on 11/28/21;
-11/28/21 was the first time that the area was reported to him/her;
-He/she notified the physician.
During an interview on 12/10/21 at 10:18 A.M. the former Director of Nursing (DON) said:
-He/she was unaware of the black area on the second toe on the right foot, until 11/28/21.
During an interview on 12/10/21 at 12:42 P.M. LPN D said:
-He/she had been the wound nurse several months ago, but resigned as he/she had not received any training and was being pulled to the floor to work as a nurse on the floor;
-There is currently no wound nurse in the facility;
-He/she was unaware of any skin issue for the resident, until the nurse found the area to the second toe on the right foot and the resident went to the hospital;
-He/she is not aware of any other skin issues for the resident.
Review of the medical record dated 12/12/21 through 12/22/21 showed:
- No treatment for wound on the left foot.
During an interview on 12/15/21 at 1:59 P.M. the former Administrator said:
-Nurses will document in the Risk Management area in Point Click Care (PCC), the electronic medical record. The Interdisciplinary Team (IDT) team will review the information to see if they need to add any information. The administration will then review the information and then lock it the entry in PCC. She can see an entry in the Risk Management section for the resident dated 12/10/21 of a new skin issue. An aide alerted the nurse that the resident had a new skin issue to 5th digit on the left foot, the wound was cleansed and dressed.
-She would expect that a wound report would be completed , and reported to wound care plus (the outside wound care provider), and the Director of Nursing (DON) should have done the wound report. The DON would have been in charge of doing t[TRUNCATED]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to store food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This affects all residents who receiv...
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Based on observation, interview and record review, the facility failed to store food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This affects all residents who receive food from the facility's kitchen. The facility census was 104.
Review of the Food Service Inspection form, dated 10/7/21, completed by the Registered Dietitian, showed he marked the kitchen as non-compliant in the following areas:
- Food Service -Refrigeration: thermometers in the front section of each unit; open packages/leftovers sealed and dated with expiration date; expired foods discarded; leftover potentially hazardous foods are dated with three day expiration date; leftover condiments/dressings/pickles, etc. are dated with 30-day expiration date; leftover cooked eggs, fish and potentially hazardous mixed dishes are discarded (eggs was circled); frozen/refrigerated supplements dated 14 days from date of thawing; shelving is free of spills and soil; fans and condensers (in units) are clean and free of dust and/or mold; walk-in cooler floors clean, handwritten note read bases of reach-ins need cleaning;
- Food storage- Storerooms: Opened packages are sealed and dated with an expiration date; storeroom floor is clean;
- Warewashing: sanitizer is at 50 parts per million (ppm) with greater than 110-120 degree Fahrenheit (F) temperature, or sanitizing temperature is greater than 180 degrees F; sanitizer strips are available for dish machine and pot sink with a handwritten note of expired in the line;
- Sanitation: Refrigeration units clean and organized; knife racks, can opener are clean (can opener was circled); ice machine is cleaned monthly and free of mildew (hand written note of sides/interior needing cleaning); dishroom is clean; floor throughout the department is swept and mopped (with a handwritten note of under tables/equipment and against the walls);
- Safety: Rubber guard in place on garbage disposal and in good repair;
- Personnel: hair covering used; hands routinely washed;
- Maintenance: air gap maintained on ice machine; light fixtures are clean; sprinkler heads are clean; refrigerator/freezer and fan covers free of dust and/or mold;
- Comments: Bag of dry spice in storeroom not labeled; unmarked cereal bins; trash stacked outside trash can with no liner; mold/buildup on vents in upper portion of reach-in on gaskets; several items (leftovers) not labeled in reach-in (pineapple, cherry, pie filling); open condiment bottles need open dates; chlorine test strips are expired; no lid on trash can; pureed fish very bland; out of date temperature logs.
Review of the facility's Date Marking for Food Safety, dated 11/1/21, showed:
-1. The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food.
Time/temperature control for safety food (formerly potentially hazardous food) includes an animal food that is raw or heat-treated; a plant food that is heat-treated or consists of raw seed sprouts, cut melons, cut leafy greens, cut tomatoes or mixtures of cut tomatoes that are not modified in a way so that they are unable to support pathogenic microorganism growth or toxin formation; or garlic-in-oil mixtures that are not modified in a way so that they are unable to support pathogenic microorganism growth or toxin formation.
1.
Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days.
2.
The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.
3.
The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.
4.
The marking system shall consist of a color-coded label, the day/date of opening and the day/date the item must be consumed or discarded.
5.
The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.)
6.
The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly.
7.
The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed.
8.
Note: prepared foods that are delivered to the nursing units shall be discarded within two hours, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified.
Review of the facility's Dishwasher Temperature policy, dated 11/1/21, showed:
-It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures.
-1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items.
-3. For high temperature dishwashers (heat sanitization):
a. The wash temperature shall be 150-165 degrees Fahrenheit
b. The final rinse temperature shall be 180 degrees Fahrenheit or above but not to exceed 194 degrees Fahrenheit (165 degrees Fahrenheit for the stationary rack, single temperature machine.)
-4. For low temperature dishwashers (chemical sanitization):
a. The wash temperature shall be 120 degrees Fahrenheit
b. The sanitizing solution shall be 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse.
Review of the facility's Sanitation Inspection policy, dated 11/1/21, showed:
-It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food services areas are clean, sanitary, and in compliance with applicable state and federal regulations.
1. All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies and other insects.
1. Observation of the kitchen on 12/9/21 at 1:00 P.M. showed the following
- Refrigerator 2 had cracked and missing tiles under it.
- Freezer had cracked and missing tiles under it.
- Tiles missing under the ice machine.
- Ceiling in the pantry had an area in the ceiling where the sheetrock had an approximately one inch gap where the sheetrock in the ceiling did not meet up with the wall. The was an approximately six inch long piece of yellow insulation hanging down from a hole in the ceiling over the sugar bin.
- Dust on the fire suppression pipe over the stove.
- Rusted racks in Refrigerator One.
- Dust on the sprinkler head by the refrigerator.
- Table under where the drinks are prepared has peeling paint on the second and third shelves.
- Large vent over serving steam table has peeled/chipped paint.
- Vent in dietary manager's office covered with dust.
- Floors under the legs of the ovens and other areas thick with black, sticky substance around the legs.
During an interview on 12/9/21 at 1:20 P.M., the dietary manager (DM) said he could not remember the last time housekeeping came into the kitchen to strip, wax and clean the floors. The cracked and missing tiles occurred when a pipe broke causing a flood in the kitchen. That is also why the ceiling had the sheetrock replaced. Maintenance started fixing the ceiling but have not finished it.
During an interview on 12/10/21 at 11:00 A.M., the Registered Dietician (RD) said he has seen the hole and was aware of the insulation hanging down. He said maintenance should fix it.
Observation on 12/10/21 at 2:28 P.M. showed:
- Nothing documented on the temperature logs on the freezers;
- Hamburger and hotdog buns and a bag of Brussel sprouts in the freezer which appeared freezer burnt with ice buildup inside the bags;
- A bag of frozen wild blueberries was open to air in the freezer;
- Sprinkler heads above the food preparation table in the middle of the kitchen covered with dust and dirt hanging from the head;
- The floors under the ice machine with no tiles, the concrete appeared to be breaking up with a white buildup that could be scraped off with a fingernail;
- Broken floor tiles under the commercial oven;
- Food on the floor between the commercial oven and convection oven;
- Food splattered on the ceiling above the dishwashing area.
Observation of the kitchen on 12/14/21 at 10:44 AM showed:
-The hot water to the handwashing sink does not work. Only cold water comes from both taps.
-There were crumbs and food matter on the preparation surfaces and on the floor.
-The inside of the microwave is dirty with food matter.
-The coffee station was dirty with spilled coffee and food matter.
-In the dry storage area, there are two open one-gallon bottles of bar-b-que sauce, undated. The bottle states refrigerate after opening.
-One open bag of chips, not dated.
Observation of plating the food for lunch on 12/14/21 at 11:43 AM showed:
-DA B transferred plates from the steam table to the tray, with his/her thumb on top of the plate, while not wearing gloves.
During an interview on 12/14/21 at 2:15 PM, the [NAME] said:
-The kitchen/food preparation areas should be clean and free of crumbs/food matter.
-Gloves should be worn when plating food.
During an interview on 12/14/21 at 2:18 PM, DA B said:
-Gloves should be worn when plating food
-He/she got nervous and in a hurry and forgot to put them on.
During an interview on 12/14/21 at 2:21 PM, the Dietary Manager said:
-After opening, food items should be sealed and dated when the item is opened.
-The kitchen and food preparation areas should be kept clean and tidy.
-Gloves should be worn when plating food.
2. Observation and interview on 12/10/21 at 2:45 P.M., showed Dietary Aide (DA) A washed the dishes from the noon meal. He/she used a test strip to test the sanitizer level. The strip did not register above 50 ppm. He/she used several more strips to test the sanitizer level and none registered above 50 ppm. In looking at the package of test strips, the container read the test strips expired in March of 2018. DA A said they had another package of test strips, went to get them and tested the sanitizer level again using the second test strip container; he/she did not write down the sanitizer level each time they checked it, only checked to make sure it was correct. This did not register above 50 ppm. This second container of test strips expired in 2020. DA A said he/she did not know for sure what the sanitizer should register.
Observation and interview on 12/10/21 at 3:30 P.M., showed the dietary manager said he found another container of test strips which had not yet expired. He tested the sanitizer level again and still did not obtain a reading above 50 ppm. He said the level should registered between 100 and 200 ppm. Staff should be checking the sanitizer level before they run the dishwasher after each meal. They did not have anywhere for staff to document the levels.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to dispose of garbage and refuse properly. The facility census was 104.
Review of the Sanitation Inspection policy, implemented on 11/1/21, show...
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Based on observation and interview, the facility failed to dispose of garbage and refuse properly. The facility census was 104.
Review of the Sanitation Inspection policy, implemented on 11/1/21, showed:
- All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.
1. Observation on 12/9/21, during the noon meal, showed uncovered 5-gallon buckets in the kitchen near the dishwashing area filled with left over food. Staff were scrapping food left on residents' plates into the buckets.
Observation and interview on 12/10/21 at 2:28 P.M., showed two uncovered 5-gallon buckets in the kitchen near the dishwashing area filled to the rim with leftover food. Dietary Aide A said the buckets were for the Director of Nursing (DON) who takes the leftovers home to his hogs.
Observation and interview on 12/10/21 at 2:40 P.M., showed the DON came into the kitchen and put lids on the buckets. He said staff put the food in the buckets for his hogs. The dietary manager said the buckets should be covered at all times unless staff are filling them.
2. Observation on 12/14/21 at 5:14 P.M., showed the facility had three large trash dumpsters. All three dumpsters were overflowing with trash, with the lids up, and 12 to 15 white trash bags on the ground beside the dumpsters.
During an interview on 12/15/21 at 12:00 P.M. the previous administrator said the trash service had not been paid so they refused to pick it up. They have paid a portion of it so they came and emptied the dumpsters. There should not be trash on the ground outside the dumpster. The dumpster lids should be shut to keep rodents out of them.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
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 administer the facility in a manner that enabled them to use resour...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer the facility in a manner that enabled them to use resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to keep all invoices paid in a timely manner, which caused some services to be stopped, and put the facility in jeopardy of losing life sustaining services. This had the potential to affect all residents. The facility census was 104.
1. Review of the facility's water bill, dated 11/24/21, showed:
- Current charges for 10/13/21 through 11/15/21 of $13,743.38;
- Previous balance of $58,293.31;
- Last payment made of $12,342.62.
Review of the DynaLink Communications (the facility's Internet provider) bill dated 11/5/21 showed:
- Previous balance $36,960.62;
- Payments received $19,091.42;
- Balance forward $17,869.20;
- New Charges $18,167.56;
- Total amount due $36,036.76.
Review of the facility's Evergy bill (electric bill), dated 11/9/21, showed:
- Previously billed amount $12,794.92;
- Current charges $5,685.47;
- Due upon receipt $18,480.39.
Review of the facility's MetTel (the facility's telecommunications company who handles their informational technologies), dated 11/8/21, showed:
- Previous balance $449.99;
- Payments $227.57;
- Balance forward $227.42;
- Current charges $222.42;
- Total amount due $449.84.
Review of the facility's [NAME] gas bill, dated 11/4/21, showed:
- Previous balance $2,665.83;
- Payment $889.56;
- Total current charges $1,317.36;
- Amount due $3,093.63.
Review of the facility's Waste Management trash disposal bill, dated 11/29/21, showed:
- Previous balance $2,621.85;
- Payment $1,688.57;
- Current Invoice charges $894.67;
- Total balance due by 12/29/21 $1,827.95;
- Resume service 11/16/21;
- Late payment charge for 8/27/21 Invoice 6533541: date 10/26/21 $19.52;
- Late payment charge for 9/28/21 Invoice 6561394: date 10/28/21 $21.14.
During an interview on 12/10/21 at 2:30 P.M., the previous administrator said the facility cannot make copies for the survey team. Their printer is not working and the corporation has not paid the company who makes those repairs so they will not come to the facility to make any repairs. They have to go to a sister facility to make any copies the survey team would need.
During an interview on 12/13/21 at 1:30 P.M., the Medical Director said he took over as Medical Director in March 2021. He has not been paid by the corporation since taking the position and has not been able to deal with a consistent management person during that time.
During an interview on 12/13/21 at 1:39 P.M., the activity director said she does not have enough supplies to do activities with the residents. Storage bins, markers, and other things all come out of her pocket. At times, she has to print the large calendars out herself because nine times out of ten, there is not money on the facility's credit card. She uses two different online programs to help come up with new and different activities for the residents but these programs must be paid for. She is not sure what she will do next month because she cannot spend any more money because there isn't any. She cannot sync her computer to a printer in the facility because it is an IT issue and the corporation has not paid the IT bills so they will not help. Each day she prints daily devotionals, word searches and daily reminders, but she cannot do that now. She has gone to the store to purchase activity supplies and the card has been denied. At one point they were concerned the facility's van would be repossessed. The trash has been an issue due to not paying the bill and no one would pick up the trash. She has come to work in the mornings and found shut-off notices for the water and electric on the front door. She knew of four or five months that if a staff member received a paper check rather than a direct deposit, they did not get paid. The staffing agencies are also not being paid.
Review of the disconnect notice from Evergy, found on the facility's front door on 12/15/21, showed:
- Past due amount $5,685.47;
- Total bill: $12,350.90;
- Total amount due: $5,685.47.
Review of a print out from Evergy provided by the facility on 12/15/21, showed:
- Current bill December 2021 for service dates 11/8/21 through 12/9/21;
- Amount due $6,665.43 due on 1/3/22;
- Last payment of $5,685,47 received on 12/15/21;
- Next bill available on 1/13/22.
During an interview on 12/15/21 at 4:45 P.M., the previous administrator said they had received a disconnect notice from Evergy. She sends all invoices to Chicago for the corporate office to pay the invoices. They paid just enough to keep the lights on. She had no control of paying bills.
During an interview on 12/16/21 at 11:30 A.M., the Regional [NAME] President said the corporation has paid the Evergy bill to avoid the services being disconnected.
During an interview on 12/20/21 at 3:00 P.M., Licensed Practical Nurse (LPN) D said on 12/11/21, he/she needed to send Resident #84 to the hospital. They could not print his/her Outside the Hospital Do Not Resuscitate (OHDNR) form to send with him/her, so the previous DON told him/her to send the original. Nursing staff do not have access to printers once the office staff leave. During the day, the Minimum Data Set (MDS) coordinator will send the OHDNR, durable power of attorney (DPOA) paper work, physician's order sheet (POS) and facesheet with the residents, but on the weekends with no access to printers, they cannot send those things.
During an interview on 12/22/21 starting at 4:22 P.M., the Administrator and Regional [NAME] President said the governing body or corporation ensured the bills are paid and that they had no interruptions of services. They may owe money, but they do not feel they are at risk of any services being shut off.
During a phone interview on 12/30/21 at 11:42 A.M., with a representative from Cintas, the facility's contracted provider for their fire alarm, sprinkler system and range hood inspections and services, said:
- They had not been providing services to the facility due to the facility having outstanding bills;
- Once a facility had invoices that exceeded 90 days they put their services on hold;
- They had unpaid invoices from May 2021 that had been outstanding until around 12/20/21 when the corporate office paid the bill;
- The bills were paid around 12/20/21 and they were current now.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both...
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Based on record review and interview, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. They failed to review and update the assessment as necessary and at least annually. The facility's bed capacity was 140 with a census of 104 at the time of the survey.
Review of the facility's assessment tool, provided by the facility's previous administrator and included their facility policy, on 12/15/21, showed:
- Nursing facilities will conduct, document and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents.
- Guidelines for Conducting the Assessment included:
1. To ensure the required thoroughness, individuals involved in the facility assessment should , at a minimum, include the administrator, a representative of the governing body, the medical director and the director of nursing (DON). The environmental operations manager, and other department heads should be involved as needed. Facilities are encouraged to see input from residents, their representatives, or families and consider that information when formulating their assessment.
2. While a facility may include input from its corporate organization, the facility assessment must be conducted at the facility level.
3. The facility must review and update this assessment annually or whenever there is or the facility plans for any change that would require a modification to any part of this assessment. For example, if the facility decides to admit residents with care needs who were previously not admitted .
Review of the Facility Assessment Tool, updated on 11/8/21 showed:
- Our resident profile:
1.1. Indicate the number of residents you are licensed to provide care for: 160
1.2 Indicate your average daily census: 100-105.
1.5 Acuity: Describe your residents' acuity levels that help you understand potential implications regarding the intensity of care and services needed. The intent of this is to give an overall picture of acuity - over the past year, or during a typical month.
- The form included a table for Major RUG-IV Categories (resource utilization groups, with determine Medicare reimbursements). The facility did not complete this table with the number/average or range of residents included in those categories.
- A second table was included for Special Treatments and Conditions. These included:
*Cancer treatments: chemotherapy- 0, radiation- 0;
*Respiratory treatments: oxygen therapy- 35 residents, suctioning- 0, tracheotomy care- 0, BiPap/CPAP (bilevel positive air pressure ventilator/continuous positive airway pressure therapy);
*Mental health: Behavior health needs- 25; active or current substance use disorders- 0;
*Other: IV medications- 0, injections- 0, transfusion- 0, dialysis- 2, ostomy care- 2, hospice care- 7, respite care- 0, isolation or quarantine for active infectious disease- 0.
- A third table included Assistance with Activities of Daily Living (ADL). Staff did not complete any of the information for this table. The table asked for what type of assistance residents needed with dressing, bathing, transfer, eating, toileting, other care and mobility.
- Ethnic, cultural, or religious factors:
* We are in a rural community and do not have wide ethnic and cultural factors at this time, however, if we had an admission with someone with ethnic or culture different than what we have had, we would do a thorough assessment with this resident to make sure we are meeting their personal needs and care plan accordingly. We have residents with several different religious backgrounds and we offer a wide variety of religions for our church and bible study services and would invite and involve a specific religion if we did not already provide that.
- 3.6 Describe your plan to recruit and retain enough medical practitioners who are adequately trained and knowledgeable in the care of your residents/patients, including how you will collaborate with them to ensure that the facility has enough appropriate medical practices for the needs and score of your population:
*We currently have a good working relationship with the medical clinic next door to our facility. They (named specific physicians who did not practice in the city where the facility is located) currently oversee more than 50% of our residents. We also have good working relationships with doctors in nearby communities that follow many of the residents from those communities (listed the names of specific physicians who practiced medicine in a small northwest Missouri community).
Observations and interviews on all days of the survey beginning on 12/9/21, at various times of the day, showed:
- Multiple residents who had different cultural backgrounds; one resident only spoke Korean, one resident spoke only Spanish, multiple residents had English as a second language;
- The location of the facility was actually in a metropolitan area, with no medical clinics next door to the facility;
- The physicians listed in the actual Facility Assessment did not provide care to any residents in the facility;
- Multiple residents with diagnoses of substance abuse; and more than 25 of the residents had diagnoses of mental health disorders;
- The facility had a large therapy department with a large number of residents receiving some type of therapy services.
During an interview on 12/15/21 at 12:00 P.M., the previous administrator said she had started to revise the facility assessment, but had only just started it. They had not had any Quality Assessment and Assurance (QAA)/Quality Assurance, Performance Improvement (QAPI) committee meetings in a while. They had this on the agenda. She did not know when the last facility assessment had been completed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure they employed a qualified social worker on a full-time basis. The facility had a capacity of 140, with a census of 104 at the time o...
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Based on record review and interview, the facility failed to ensure they employed a qualified social worker on a full-time basis. The facility had a capacity of 140, with a census of 104 at the time of the survey.
Review of the Social Services policy, implemented on 11/1/21, showed the facility will, regardless of size, provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental and psychosocial well being.
- Medically-related social services are services provided by the facility's staff to assist residents in attainment or maintenance of a resident's highest practicable well-being.
- A facility with more than 120 beds will employ a qualified social worker on a full-time basis. A qualified social worker is an individual with:
a. A bachelor's degree in social worker or a bachelor's degree in a human services field including but not limited to sociology, gerontology, special education, rehabilitation counseling, and psychology;
b. One year of supervised social work experience in a health are setting working directly with individuals.
Review of the Employee Information Default list, printed on 12/9/21, showed:
- A list of all active employees and their job titles;
- The list did not include any staff working under a job title of Social Services.
During the entrance conference for the annual survey, held on 12/13/21 at 12:06 P.M., the previous administrator said they did not currently have a qualified social worker. The previous social worker left a while ago, but she did not know how long he/she had been gone. They were currently sharing an admissions coordinator with a sister facility, but he/she was not employed full time. He/She can only do so much on a part-time basis. They have a new social service staff who was scheduled to start work on 12/20/21.
During an interview on 12/22/21 at 4:22 P.M., the new administrator and new Regional [NAME] President said they had a new social services staff member who was to start on 12/20/21, but after they found some troubling information and possible sabotage with staff who are no longer working at the facility, that person will not be working for them. They do not know exactly when the previous social service staff was last employed, but feel he/she had been gone for over a month.
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 record review and interview, the facility failed to develop quality assessment and assurance (QAA) activities and a quality assurance/performance improvement (QAPI) plan which drives the faci...
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Based on record review and interview, the facility failed to develop quality assessment and assurance (QAA) activities and a quality assurance/performance improvement (QAPI) plan which drives the facility's ability to address any areas of concern and to correct any quality deficiencies identified by the QAPI process. The facility census was 104.
The facility did not provide a policy for their QAA/QAPI committee and process.
Review of the QAA/QAPI manual, showed the manual contained minutes and documentation from March of 2021, on 3/18/21. The manual contained no other meeting minutes for 2021 to indicate that meetings were completed.
During an interview and record review on 12/15/21 at 2:07 P.M., the previous Administrator said she was in charge of QAA and QAPI (quality assurance/performance improvements). She took over as administrator in October 2021. She scheduled the first meeting for yesterday, 12/14/21, and it did not take place. Since she has been at the facility, she has not found any paperwork for QA or QAPI. She found the QAA/QAPI book during this interview. No meetings had been held for 2021.
-Meetings should be held one time a month. The medical director should be attending quarterly and usually all department managers (maintenance, dietary manager, Director of Nursing, wound nurse, floor staff) attend monthly. QAA/QAPI consists of discussions on weight loss, pressure ulcers, staffing, falls/accidents, and resident/family concerns. Since October 2021, she has identified multiple areas of concerns involving all departments but has not been able to focus on the concerns due to not having a DON and not having clinical leadership and support from the corporate level. They have not had a turnover in activities or maintenance; however, the dietary manager and business office manager are new within the last 90 days. The administrator said they currently have high acuity residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure they developed and implemented appropriate plans of action to correct identified quality deficiencies as a part of their QAA (qualit...
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Based on record review and interview, the facility failed to ensure they developed and implemented appropriate plans of action to correct identified quality deficiencies as a part of their QAA (quality assessment and assurance) committee. The facility census was 104.
Record review of the facility's undated list of Quality Assurance/Performance Improvement (QAPI) Committee Members showed:
- Members include the Administrator, Director of Nursing, QAA nurses, Social Worker and Social Services designees, Business Office Manager, Minimum Data Set (MDS: a federally mandated assessment instrument completed by the facility) Coordinator, Housekeeping Supervisor, Dietary Supervisor, Activity Director, Admissions Coordinator, Maintenance Director, Medical Records, Medical Director, Therapy Coordinator, Registered Dietician, Pharmacy Representative, and Lab Representative;
- QAPI meetings held quarterly.
The facility did not provide a policy for QAA/QAPI or a QAA/QAPI plan.
Record review of the QAA/QAPI manual, showed the manual contained minutes and documentation from March of 2021, on 3/18/21. The manual contained no other meeting minutes for 2021 to indicate that meetings were done. The manual did not document areas of concern and plans developed to correct these identified concerns.
During an interview and record review on 12/15/21 at 2:07 P.M., the previous Administrator said she was in charge of the QAA and QAPI programs. She took over as administrator in October 2021. She scheduled the first meeting for yesterday, 12/14/21, and it did not take place. Since she has been at the facility, she has not found any paperwork for QAA or QAPI. She found the QAA/QAPI book during this interview. No meetings had been held for 2021.
-She expected that meetings should be held one time a month. The medical director should be attending quarterly, usually all department managers (maintenance, dietary manager, Director of Nursing, wound nurse, floor staff) attend the monthly meetings.
- QAA/QAPI consists of discussions on weight loss, pressure ulcers, staffing, falls/accidents, resident/family concerns.
- Since October 2021, she has identified multiple areas of concerns involving all departments, but has not been able to focus on the concerns due to not having a DON and not having clinical leadership and support from the corporate level. They have not had a turnover in activities or maintenance; however, the dietary manager and business office manager were new within the last 90 days. They currently have residents with high acuity.
During an interview on 12/20/21 at 5:00 P.M.,. the Medical Director said;
-He has not attended a QAA/QAPI meeting the entire year of 2021;
-The facility has not had a consistent Administrator or Director of Nursing to have a meeting;
-If he wanted to know what was occurring in the facility he would talk with the MDS coordinator.
At the time of the survey exit, the facility had not been able to provide the QA book.
During an interview on 12/22/21 at 5:30 P.M., the Regional [NAME] President said the facility would follow all federal and state rules and regulations.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed to identify issues with respect to ...
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Based on record review and interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed to identify issues with respect to which quality assessment and assurance activities are necessary. The facility census was 104.
Review of the QAA/QAPI (Quality Assurance/Performance Improvement) manual, showed the manual contained minutes and documentation from March of 2021, on 3/18/21. The manual contained no other meeting minutes for 2021 to indicate that meetings were completed.
During an interview and record review on 12/15/21 at 2:07 P.M., the previous Administrator said she was in charge of QAA and QAPI (quality assurance/performance improvements). She took over as administrator in October 2021. She scheduled the first meeting for yesterday, 12/14/21, and it did not take place. Since she has been at the facility, she has not found any paperwork for QA or QAPI. She found the QAA/QAPI book during this interview. No meetings had been held for 2021. Meetings should be held one time a month. The medical director should be attending quarterly, usually all department managers (maintenance, dietary manager, Director of Nursing, wound nurse, floor staff) attend the monthly meetings.
During an interview on 12/15/21 at 2:07 P.M., the administrator said the facility has not had an active QAA/QAPI committee since March, 2021. The current administrator had not been able to locate records showing evidence the committee had met.
During an interview on 12/20/21 at 5:00 P.M., the Medical Director said;
-He has not attended a QAA/QAPI meeting the entire year of 2021;
-The facility has not had a consistent Administrator or Director of Nursing to have a meeting;
-If he wanted to know what was occurring in the facility he would talk with the MDS (Minimum Data Set -a federally mandated assessment instrument) coordinator.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to maintain documentation to show they established an infection prevention and control program (IPCP) which included, at a minimum, an antibio...
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Based on record review and interview, the facility failed to maintain documentation to show they established an infection prevention and control program (IPCP) which included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 104.
Review of the facility's Infection Surveillance policy, implemented on 11/1/21, showed a system of infection surveillance serves as a core activity of the facility's IPCP. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and controls practices in order to reduce infections and prevent the spread of infections. Infection surveillance refers to an ongoing systematic collection, analysis, interpretation and dissemination of infection-related data. The policy listed the following compliance guidelines:
- The designated Infection Preventionist (IP) serves as the leader in the surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility and reports the surveillance findings to the facility's Quality Assessment and Assurance (QAA) committee and the public health authorities when required.
- Nurses participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. Examples of notification triggers include but are not limited to:
a. Resident develops signs and symptoms of infection
b. A resident is started on an antibiotic
c. A microbiology test is ordered
d. A resident is place on isolation precautions, whether empirically or by physician order
e. Microbiology test results show drug resistance
- An annual infection control risk assessment will be used to prioritize surveillance efforts, as documented in the facility's Infection Surveillance Action Plan. In turn, surveillance data will provide information for subsequent infection control risk assessments.
- Surveillance activities will be monitored facility-wide, and may be broken down by department or unit, depending on the measure being observed. A combination of process and outcome measures will be utilized.
- Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends.
- All resident infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. Outbreaks will be investigated.
- Employee, volunteer and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection outbreaks.
Review of the Resident Matrix, a form completed by facility staff which documents resident conditions, completed on 12/9/21, showed staff listed five residents with infections.
During an interview on 12/13/21 at 12:06 P.M., the previous administrator said the Director of Nursing (DON) was the IP. He had all of the documentation to show their IPCP surveillance.
Review of the Resident Census and Conditions of Resident, completed by facility staff on 12/14/21, showed the facility reported they nine residents currently received antibiotics.
During an interview on 12/21/21 at 11:57 A.M., the interim DON said she did not know who the IP was and she did know anything about the IPCP.
During an interview on 12/21/21 at 11:59 A.M., Corporate Nurse B said the previous DON was in charge of tracking and trending infections. All of that documentation had been in his office but now they cannot find any documentation to show the facility had an IPCP.
During an interview on 12/22/21 at 4:22 P.M., the administrator, Corporate Nurse B and interim DON said:
- They are in the process of hiring a new IP but they will monitor in the meantime.
- There is a program called McGeer Criteria for Long Term Care surveillance, but they did not know if that was currently being done. The previous DON had the information in his office but now they cannot find any of it.
- The IP will be handling the antibiotic stewardship program; the interim DON is monitoring this.
The facility did not provide any documentation to show they have an antibiotic stewardship program.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to employ an infection preventionist (IP) on at least a part-time basis. The facility census was 104.
Review of the facility's Infection Surve...
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Based on record review and interview, the facility failed to employ an infection preventionist (IP) on at least a part-time basis. The facility census was 104.
Review of the facility's Infection Surveillance policy, implemented on 11/1/21, showed a system of infection surveillance serves as a core activity of the facility's infection prevention and control (IPC) program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. The policy included the following guidelines:
- The designated IP serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance (QAA) Committee, and public health authorities when required.
During an interview on 12/13/21 at 12:06 P.M., the previous administrator said the Director of Nursing (DON) is their IP.
During an interview on 12/21/21 at 11:57 A.M., the interim DON said she did not know who the IP is now that the previous DON is no longer employed at the facility. She did not have any knowledge of the IPC program.
During an interview on 12/22/21 at 4:22 P.M., the Administrator said the previous DON was the facility's IP. They are in the process of hiring a new IP. The previous DON had all of the IPC information in his office, but now they cannot find any of that information.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to inform residents, their representatives and families following the occurrence of either a single confirmed infection of COVID-19, or three ...
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Based on record review and interview, the facility failed to inform residents, their representatives and families following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset respiratory symptoms occurring within 72 hours of each other. The facility census was 104.
Review of the facility's COVID-19 and COVID-19 Vaccine Reporting policy, implemented on 1/11/21, showed it is the policy of this facility to share appropriate information regarding COVID-19 and COVID-19 vaccines with staff, residents and their representatives, and to report COVID-19 information to the local/state health department and Centers for Disease Control and Prevention (CDC). The policy gave the following compliance guidelines:
- Residents, their representatives and families are notified of the conditions inside the facility related to COVID-19:
- By 5:00 P.M., the next calendar day following the occurrence of either:
i. A single confirmed infection of COVID-19
ii. Three or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours of each other (example: outbreak).
- Cumulative updates will be provided weekly by 5:00 P.M. the next calendar day following the subsequent occurrence of either:
i. Each time a confirmed infection of COVID-19 is identified;
ii. Whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other (outbreak);
- Cumulative weekly updates will also include:
i. Mitigation activities implemented to prevent or reduce the risk of transmission
ii. Any changes in normal operations of the facility (altered restriction or limitations on visiting, group activities, etc.).
Review of the Department of Health and Senior Services' positive COVID-19 results from nursing facilities, dated 10/20/21, showed the facility reported one positive staff person.
During an interview on 12/13/21 at 12:06 P.M., the previous administrator said the social worker (SW) shares information on the facility's COVID-19 status with families, residents and their representatives. Their previous SW would send out letters and emails to keep families, residents and their representatives up to date on the facility's COVID-19 status. He is no longer employed with the facility and they have not had anything to report since he has been gone. They currently do not have any positive COVID residents or staff in the building.
During an interview on 12/13/21 at 1:44 P.M., Family Member (FM) B said:
-He/she is the Power of Attorney for Resident #66;
-He/she has not been notified recently of the any COVID-19 positive residents or staff.
During an interview on 12/14/21 at 11:30 A.M., FM A said:
-He/she is the Power of Attorney for Resident #84;
-He/she has not been notified of any COVID-19 positive residents or staff;
-He/she is not aware of the COVID-19 status in the facility.
During an interview on 12/14/21 at 4:30 P.M., Resident #42 said no one had notified him/her of any testing for COVID-19 since he/she was admitted to the facility. He/she did not know if the facility had any current or had had any positive test results.
During an interview on 12/22/21 at 4:22 P.M., the Administrator said the facility had a staff member test positive on 12/21/21. The admissions coordinator and the Minimum Data Set (MDS) coordinator notified residents and their responsible parties. She did not know who was responsible for weekly notifications.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
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 perform routine staff testing for COVID-19 in accordance with Cente...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to perform routine staff testing for COVID-19 in accordance with Center for Disease Control (CDC) guidelines, when the facility failed to test staff at the required frequency based on the county COVID-19 transmission rate. The county transmission rate was listed as high and required testing two times a week.
Review of the facility policy for Coronavirus Testing, dated 11-1-2021, showed:
Policy: The facility will implement testing of facility residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19. COVID-19 (short for coronavirus disease 2019) is a new respiratory disease caused by a novel (new) coronavirus)
Policy Explanation and Compliance Guidelines:
1.
The facility will conduct testing through the use of rapid point-of-care (POC) diagnostic testing devices or through an arrangement with an offsite laboratory.
Review of the undated facility policy for Novel Coronavirus Prevention and Response showed:
-Policy: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus;
Considerations/priorities for testing:
a. Use clinical judgement on case-by-case basis to determine if a resident has signs and symptoms compatible with COVID-19;
b. Test for other causes of respiratory illness, such as influenza or other respiratory panels;
c. Testing for COVID-19 will occur for staff or residents with signs or symptoms of COVID-19, outbreaks with the facility, and routinely following the frequency guidance according to the facility's level of community transmission.
During an interview on 12/21/21 at 11:57 A.M., the interim Director of Nursing (DON) said:
-COVID testing should be done 2 times a week. She does know who or what type of testing is done;
-The former DON was in charge of the COVID testing, but left the faciity on [DATE];
-Point Of Care (POC, rapid tests) tests were being done, but she cannot find where the results are documented;
-She has looked in the DON office and cannot find any COVID test results;
-The interim DON said they had not tried to contact the previous DON for this information.
During an interview on 12/21/21 at 2:47 P.M., Licensed Practical Nurse (LPN) H said:
-He/she is an agency nurse, and has worked several shifts at the facility, but 12/20/21 was the first time he/she was tested at this facility.
During an interview on 12/21/21 at 2:47 P.M., Certified Nurse Aide (CNA) G said:
-He/she is an agency CNA and this is his/her first shift at this facility;
-He/she did not test before he/she started work.
During an interview and observation on 12/20/21 at 3:30 P.M., Assistant Activity Director said:
-He/she will cover the front desk at times;
-Employees test when they come in to work;
-The rapid test cards and testing sheets are on a cart in the copy room;
-He/she does not know who reads the tests or ensures that all employees have tested;
-He/she handed a stack of testing sheets and rapid cards to the surveyor. There were two rapid cards from 12/18/21, two rapid cards from 12/19/21, five rapid cards from 12/20/21, and two rapid cards from 12/21/21;
-Only three were documented as being read as negative;
-The Activity Assistant Director said that a nurse is supposed to read the cards.
During an interview on 12/22/21 at 4:22 P.M., the interim DON and Corporate Nurse B said:
-The DON is responsible for documenting individual COVID-19 results sheets and ensuring staff are tested per the regulations and county transmission rate;
-The results of the COVID-19 tests should be read within the appropriate time frame of the test, which is 15 minutes.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure they maintained documentation to show they provided training to their staff on activities that constitute abuse, neglect, exploitati...
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Based on record review and interview, the facility failed to ensure they maintained documentation to show they provided training to their staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. The facility census was 104.
The facility could not provide documentation to show they provided training to all staff on abuse neglect, exploitation and misappropriation of resident property when requested.
During an interview on 12/22/21 at 4:22 P.M., the interim Director of Nursing (DON), Corporate Nurse B and administrator said human resources (HR) tracks the staff education. They do not have an HR staff right now, he/she left employment on 12/10/21. If they do not have an HR staff, the administrator or DON provide the training. Their previous DON quit without notice on 12/13/21 and the previous administrator's last day of employment was 12/15/21. They cannot find a lot of personnel records.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 3 harm violation(s). Review inspection reports carefully.
- • 101 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $14,267 in fines. Above average for Missouri. Some compliance problems on record.
- • Grade F (6/100). Below average facility with significant concerns.
Bottom line: Trust Score of 6/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Avalon View Health And Wellness's CMS Rating?
CMS assigns AVALON VIEW HEALTH AND WELLNESS 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 Avalon View Health And Wellness Staffed?
CMS rates AVALON VIEW HEALTH AND WELLNESS's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 62%, which is 15 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Avalon View Health And Wellness?
State health inspectors documented 101 deficiencies at AVALON VIEW HEALTH AND WELLNESS during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 97 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Avalon View Health And Wellness?
AVALON VIEW HEALTH AND WELLNESS 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 VERTICAL HEALTH SERVICES, a chain that manages multiple nursing homes. With 140 certified beds and approximately 110 residents (about 79% occupancy), it is a mid-sized facility located in LIBERTY, Missouri.
How Does Avalon View Health And Wellness Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, AVALON VIEW HEALTH AND WELLNESS's overall rating (1 stars) is below the state average of 2.5, staff turnover (62%) 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 Avalon View Health And Wellness?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Avalon View Health And Wellness Safe?
Based on CMS inspection data, AVALON VIEW HEALTH AND WELLNESS has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 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 Avalon View Health And Wellness Stick Around?
Staff turnover at AVALON VIEW HEALTH AND WELLNESS is high. At 62%, the facility is 15 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 60%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Avalon View Health And Wellness Ever Fined?
AVALON VIEW HEALTH AND WELLNESS has been fined $14,267 across 1 penalty action. This is below the Missouri average of $33,222. 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 Avalon View Health And Wellness on Any Federal Watch List?
AVALON VIEW HEALTH AND WELLNESS 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.