PIONEER SKILLED NURSING CENTER
For profit - Corporation
96 Beds
AMERICARE SENIOR LIVING
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
23/100
#285 of 479 in MO
Photo by Pioneer Rehabilitation & Skilled Nursing
Photo by Pioneer Rehabilitation & Skilled Nursing
Photo by Pioneer Rehabilitation & Skilled Nursing
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Pioneer Skilled Nursing Center has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #285 out of 479 nursing homes in Missouri, placing it in the bottom half of all facilities, but it is the top choice in Chariton County, where it ranks #1 out of 3. Unfortunately, the facility's performance is worsening, with issues increasing from 3 in 2024 to 7 in 2025. Staffing is a weak point, with a low rating of 1 out of 5 stars and a turnover rate of 53%, which is still slightly below the state average. The facility has incurred $76,961 in fines, which is higher than 85% of other facilities in Missouri, raising concerns about compliance. There are also serious incidents reported, including a failure to notify a physician about a resident's worsening condition, which led to hospitalization, and instances of abusive behavior by staff towards residents. Overall, while there are some strengths, like average RN coverage, the weaknesses in staffing and serious compliance issues make this facility a concerning choice for families.
- Trust Score
- F
- In Missouri
- #285/479
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $76,961 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 41%
Review needed
3 → 7 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 7 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Near Missouri average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 53%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Federal Fines: $76,961
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: AMERICARE SENIOR LIVING
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 22 deficiencies on record
1 life-threatening 1 actual harm
Mar 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the current fall interventions for one re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the current fall interventions for one resident (Resident #21), in a review of 14 sampled residents, had been reviewed for effectiveness or that his/her care plan was updated with additional interventions after falls. The facility also failed to ensure their Fall Prevention Program policy was followed. The facility census was 47.
Review of the facility policy, Fall Prevention Program, last revised August 2024, showed the following:
-Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls;
-The facility utilizes a standardized risk assessment for determining a resident's fall risk;
-The risk assessment categorizes residents according to low, moderate, or high risk;
-For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment;
-Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk;
-The nurse will indicate, by completing the fall risk assessment the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk;
-The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions;
-Low/Moderate Risk Protocols:
a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to, call light and frequently used items are within reach;
b. Implement routine rounding schedule;
-High Risk Protocols:
a. The resident will be placed on the facility's Fall Prevention Program;
i. Indicate fall risk on care plan;
ii. Place Fall Prevention Indicator (such as a star, color coded sticker) on the name plate to the resident's room;
iii. Place Fall Prevention Indicator on resident's wheelchair;
b. Implement interventions from Low/Moderate Risk Protocols;
c. Provide interventions that address unique risk factors measured by the risk assessment tool;
d. Provide additional interventions as directed by the resident's assessment, including, but not limited to:
i. Assistive devices;
ii. Increased frequency of rounds;
vii. Scheduled ambulation or toileting assistance;
-Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care;
a. Interventions will be monitored for effectiveness;
b. The plan of care will be revised as needed;
-When any resident experiences a fall, the facility will:
e. Review the resident's care plan and update as indicated;
f. Document all assessments and actions.
1. Review of Resident #21's undated face sheet showed the following:
-The resident admitted to the facility on [DATE];
-Diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (a group of conditions that cause a decline in memory, thinking, and other cognitive skills, significantly impacting a person's ability to perform daily activities), osteoporosis (a condition in which bones become weak and brittle), fracture of sacrum (a large, triangular bone at the base of the spine that forms the back wall of the pelvis) and repeated falls.
Review of the resident's admission fall risk evaluation, dated 10/02/24, showed the following:
-He/She had a history of one to two falls in the past three months;
-He/She was alert and oriented;
-He/She was ambulatory;
-He/She was continent of bowel and bladder;
-He/She was recently hospitalized due to a fall;
-He/She had a balance problem while standing and walking;
-He/She had decreased muscular coordination;
-He/She required use of assistive devices;
-He/She had a fall risk score of 16 (High Risk for Falls).
Review of the resident's medical record showed no documentation to support the resident was on a routine rounding schedule (per facility policy, interventions for a high risk score included implementing interventions from the low/moderate risk interventions which included a routine rounding schedule.
Review of the resident's baseline care plan, dated 10/02/24, showed the following:
-Reason for stay: Fall at ALF (assisted living facility) with fracture to sacrum;
-Mobility: Assist of one staff, used walker and wheelchair;
-Toileting: Assist of one or two staff, incontinent of bowel and bladder;
-Safety: History of falls;
-Risks and Illnesses: Falls;
-No level of risk indicated;
-No interventions listed.
Review of the resident's comprehensive care plan, initiated 10/11/24, showed the following:
-Safety and Fall risk; I've had recurrent falls;
-The resident's memory and decision-making process may not be as reliable as it used to be; he/she can become confused and forgetful with any change in environment or routines; he/she might forget safety factors, so he/she needs his/her caregivers to help him/her stay as safe as possible.
There were no intervention listed to prevent falls in this care plan.
Review of the resident's progress notes, dated 10/18/24, showed staff documented the resident was found on the floor after attempting to transfer himself/herself from the wheelchair to the recliner.
Review of the resident's comprehensive care plan showed it was updated on 10/18/24 to show the resident fell while attempting to move from his/her wheelchair to his/her recliner unassisted. The care plan had no interventions for falls listed.
Review of the resident's medical record, including the post fall evaluation and care plan, showed no documentation the plan was updated with fall interventions after the fall on 10/18/24.
Review of the resident's progress notes, dated 12/30/24 at 2:45 P.M., showed staff documented the resident said he/she got up from his/her recliner to put a book away, walked around the wheelchair to get back to his/her recliner, leaned on the wheelchair causing it to tip over and fell, causing a skin tear to the right elbow.
Review of the post fall evaluation showed the resident's wheelchair was involved in the fall and that the wheelchair had been left unlocked at the time of the fall.
Review of the resident's medical record, including the post fall evaluation and care plan, showed no documentation the plan was updated to document this fall or with fall interventions added after this fall.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 01/09/25, showed the following:
-Cognition intact;
-Required supervision/touching assistance from staff for transfers;
-Required supervision/touching assistance from staff for walking;
-Adequate vision; did not wear glasses or corrective lenses;
-Dependent on staff for wheelchair mobility;
-Used a manual wheelchair;
-Used a walker;
-Had one fall with no injury and two or more falls with injury since admission or prior assessment.
Review of the resident's 90 day fall risk evaluation, dated 01/09/25, showed the following:
-He/She had a history of three or more falls in the past three months;
-He/She was alert and oriented;
-He/She was ambulatory;
-He/She required use of assistive devices;
-He/She had a fall risk score of 13 (Medium Risk for Falls).
The facility policy did not address protocols or interventions for a medium risk scores.
Review of the resident's comprehensive care plan, revised 01/23/25, showed the following:
-Dependent with locomotion, required assistance of one staff;
-Required supervision or touching assistance with walking, required assistance of one staff;
-Required supervision or touching assistance with transfers, required assistance of one staff;
-Required partial to moderate assistance with personal hygiene;
-Encourage/assist resident to transfer slowly and wear proper and nonslip footwear and rest when he/she was tired or not feeling well;
-The resident falls often; please answer his/her call light as quickly as possible, he/she has been educated to use it for transfers; he/she had anti-rollback mechanism placed on his/her wheelchair and visual cues placed in his/her room to remind him/her to lock the brakes while transferring to help keep him/her safe;
-Make sure the height of the bed is at an appropriate level for safety;
-Anticipate the resident's needs;
-Ensure areas are not cluttered; have commonly used items and his/her call light within easy reach and remind to ask for assistance when he/she needs it;
-The care plan did not address walker use.
Review of the resident's progress notes dated 01/27/25, showed staff documented the resident was found on the floor and hit his/her head.
Review of the post fall evaluation showed the resident's wheelchair was involved in the fall and that the wheelchair had been left unlocked at the time of the fall.
Review of the resident's comprehensive care plan showed it was updated on 01/27/25 to show it was unclear with description of actions during the time of the fall.
Review of the resident's medical record, including the post fall evaluation and care plan, showed no documentation the current fall interventions had been reviewed for effectiveness or that the plan was updated with additional interventions after this fall.
Review of the resident's progress notes, dated 03/13/25 at 4:20 P.M., showed staff documented the resident had a fall when attempting to transfer without assistance.
Review of the resident's medical record, including the post fall evaluation and care plan, showed no documentation the current fall interventions had been reviewed for effectiveness or that the plan was updated to document this fall or with additional interventions after this fall.
Observation on 03/17/25 at 11:05 A.M. showed the following:
-No star or color coded sticker on the name plate to the resident's room (as was directed by facility policy);
-The resident walked with his/her walker from his/her bathroom to his/her recliner with no assistance from staff;
-A wheelchair was close to the recliner with no fall prevention indicator posted on it (as was directed by facility policy);
-Call light laid across the bed;
-Signs posted in the resident's room included Please use call light for assistance, Do not use walker when you are alone, Please use wheelchair when getting up, To use the bathroom, please push the call light and wait for the nurses to help you, Do not get up on your own.
During an interview on 03/17/25 at 11:05 A.M., the resident said his/her call light was on the bed and out of reach so he/she just got up and went to the bathroom on his/her own. Sometimes it takes staff 25-30 minutes to answer the call light, or staff don't answer it at all, which usually resulted in a fall. He/She will holler for help if the call light was not within reach, but sometimes staff do not hear him/her or respond.
Observation on 03/19/25 at 6:05 A.M. showed the following:
-No star or color coded sticker on the name plate to the resident's room;
-Registered Nurse (RN) A assisted the resident into his/her wheelchair and then pushed the resident up to his/her sink; no fall prevention indicator was on the wheelchair.
Review of the resident's progress notes dated 03/19/2025 at 8:30 P.M., showed staff documented the resident was found on the floor next to his/her bed after toileting.
Review of the resident's medical record, including the post fall evaluation and care plan, showed no documentation the current fall interventions had been reviewed for effectiveness or that the plan was updated to document this fall or with additional interventions after this fall.
Observation on 03/20/2025 at 1:45 P.M. showed no star or color coded sticker on the name plate to the resident's room.
During an interview on 03/20/25 at 12:40 P.M., Certified Nurse Assistant (CNA) C said that the resident was probably a high risk for falls because he/she fell all the time. The only way staff know if a resident was a high fall risk was through a report or the nurse will tell them. There were no indicators such as a star or color coded sticker on their name plates or wheelchairs to indicate high risk for falls.
During an interview on 03/20/25 at 4:40 P.M., the Director of Nursing (DON) said the following:
-She would expect interventions to be put into place on the care plan after falls; it is nursing's responsibility to make sure interventions are put into place;
-She would expect staff to meet and discuss effectiveness of interventions and to put new interventions in place if current interventions were ineffective;
-She would expect the fall prevention program to be followed per facility policy.
During an interview on 03/20/25 at 5:05 P.M., the Administrator said the following:
She would expect interventions to be put into place on the care plan after falls; it is nursing's responsibility to make sure interventions are put into place;
-She would expect staff to meet and discuss effectiveness of interventions and to put new interventions in place if current interventions were ineffective;
-She would expect the fall prevention program to be followed per facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain acceptable parameters of weight for one resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain acceptable parameters of weight for one resident (Resident #39), in a review of 14 sampled residents. The facility failed to consistently provide/offer lunch for the resident to take while away from the facility on dialysis (a treatment for kidney failure, or end-stage kidney disease, that filters waste and excess fluid from the blood when the kidneys can no longer do so) days or after he/she returned, failed to document meal intake per their policy and failed to re-assess food preferences to improve intake. The facility census was 47.
Review of the facility policy titled, Nutritional Management, dated 2024, showed the following:
-The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition;
Compliance Guidelines:
1. A systematic approach is used to optimize each resident's nutritional status:
a. Identifying and assessing each resident's nutritional status and risk factors;
b. Evaluating/analyzing the assessment information;
c. Developing and consistently implementing pertinent approaches;
d. Monitoring the effectiveness of interventions and revising them as necessary;
2. Identification/assessment:
b. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay;
c. A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change of condition;
4. Care plan implementation:
a. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care;
b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to:
c. Real food will be offered before adding supplements;
5. Monitoring/revision:
a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include:
i. Interviewing the resident and/or resident representative to determine if their personal goals and preferences are being met;
v. Evaluating the care plan to determine if current interventions are being implemented and are effective.
Review of the facility policy, Weight Monitoring, dated 2024, showed the following:
-Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;
Compliance Guidelines:
Significant, unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem;
4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status;
5. A weight monitoring schedule will be developed upon admission for all residents:
c. Residents with weight loss-monitor weight weekly;
7. Documentation:
a. The physician should be informed of a significant change in weight and may order nutritional intervention;
c. Meal consumption information should be recorded and may be referenced by theinterdisciplinaryy care team as needed;
e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes.
Review of the facility policy titled, Hemodialysis, dated 2024, showed the following:
-The facility will assist that each resident receives care and services for the provision of hemodialysis consistent with professional standards of care. This will include:
d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered.
1. Review of Resident #39's care plan, dated 11/06/24, showed the following:
-The resident had a potential nutritional problem;
-Alert dietitian if the resident's consumption is poor for more than 48 hours. Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply;
-Assess for food preferences;
-Provide and serve the resident's diet as ordered. Assess the resident's intake and record meal. Offer substitutes as requested or indicated for food the resident doesn't eat. Please encourage/help the resident to eat his/her meals and snacks;
-The resident was on a renal diet, regular texture and regular liquids;
-If meals are refused, provide extra nourishment;
-The resident requires set up or clean up assistance of one staff member. Staff sets up or cleans up. The resident can feed him/herself independently. Staff assists only prior to or following his/her meal. Please set up the resident's tray by opening containers, taking off plastic and unwrapping his/her silverware;
(The resident's goals and preferences regarding nutrition were not reflected in the resident's plan of care as the facility policy instructed).
Review of the resident's weight record, dated 12/02/24, showed the resident weighed 151.9 pounds (lbs).
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/06/24 showed the following:
-Cognitively intact;
-Independent with eating;
-Weight 152 pounds;
-Weight gain, not on a physician-prescribed weight gain regimen;
-Diagnosis of end stage renal disease (a condition in which the kidneys have permanently lost most of their ability to function).
Review of the resident's weight record, dated 01/02/25, showed the resident weighed 153.1 pounds.
Review of the resident's physician's orders, dated February 2025, showed the following:
-Health Shakes one time a day for weight monitoring and supplementation with breakfast (start date 5/21/24);
-Renal diet, regular texture.
Review of the resident's weight record, dated 02/04/25 showed the resident weighed 144.3 pounds.(weight loss of 8.8 pounds or 9.4% in one month)
Review of the resident's medical record showed no documentation the facility evaluated the care plan to determine if current interventions were being implemented and effective per the facility policy.
Review of the resident's Significant Change MDS, dated [DATE], showed the following:
-Cognitively intact;
-End stage renal disease;
-Weight: 144 pounds;
-Therapeutic diet;
-No weight loss or gain.
Review of the Consultant Dietitian Report, dated 02/25/25, showed the resident did not have a progress note for the month.
Review of the resident's progress notes dated 02/27/25 (first dialysis treatment) showed the following:
-At 9:20 A.M. the resident left with family for dialysis:
-At 1:43 P.M. the resident returned from dialysis.
Review of the resident's meal intake record, dated 02/27/25 at 9:03 A.M., showed staff documented the meal as refused; no documentation to show extra nourishment was provide, or that the resident had refused, as per the care plan.
Review of the resident's physicians orders, dated March 2025, showed the following:
-Health Shakes one time a day for weight monitoring and supplement (start date 5/21/24);
-Renal diet, regular texture, regular liquids.
Review of the resident's meal intake record, dated 03/01/25 (dialysis day), showed at 10:01 A.M. refused; no documentation to show extra nourishment was provide, or that the resident had refused, as per the care plan.
Review of the resident's progress notes, dated 03/1/25 at 11:12 A.M., showed the resident left with transportation for dialysis.
Review of the resident's meal intake record, dated 03/01/25 (dialysis day), showed at 1:46 P.M., not available.
Review of the resident's progress notes, dated 03/01/25 at 6:51 P.M., showed the resident ate 100% of supper.
Review of the resident's progress notes, dated 03/4/25 at 3:06 P.M., resident out of the facility for dialysis.
Review of the resident's meal intake record, dated 03/04/25 (dialysis day), showed the following:
-At 3:19 P.M. not available;
-At 3:32 P.M. refused; no documentation to show extra nourishment was provide, or that the resident had refused, as per the care plan.
Review of the resident's Medication Administration Record (MAR), dated March 2025, showed the resident refused his/her ordered Health Shake on 03/04/25.
Review of the resident's progress notes showed staff documented on 03/04/25 at 7:53 A.M., the resident continued to refuse medications, showers, and assistance with Activities of Daily Living (ADLs). Multiple attempts have been made and resident states I don't feel like it so I'm not going to;.
Review of the resident's MAR, dated March 2025, showed the resident refused his/her ordered Health Shake on 03/05/25.
Review of the resident's progress notes showed staff documented the following:
-On 03/05/25 at 8:47 A.M. the resident refused health shake, charge nurse made aware;
-On 03/05/25 at 5:53 P.M. the resident refused dinner and was offered a health shake. The resident drank 100%.
Review of the resident's weight record, dated 03/05/25, showed the resident weighed 134.9 pounds (weight loss of 9.1 pounds or 6.3% in 14 days).
Review of the resident's medical record showed no documentation the facility evaluated the care plan to determine if current interventions were being implemented and effective per the facility policy.
Review of the resident's Skin Nutrition At Risk (SNAR) report, dated 03/05/25, showed the following:
Intake:
-Percentage of meals: 25%;
-Percentage of snacks: 25%;
-The resident had a significant weight loss;
Order changes:
-Resident recently began dialysis, had not felt well this morning related to poor kidney function and awaiting placement of dialysis access to being dialysis. Resident started dialysis recently;
-Responsible party and physician notified: Continuing to monitor weight trends for resident since addition of dialysis treatment. Continues supplement daily. Meals and fluids encouraged.
Review of the resident's care plan, revised 03/05/25, showed the resident received hemodialysis three times a week: Tuesday/Thursday/Saturday.
Review of the resident's meal intake record, dated 03/06/25 (dialysis day), at 6:09 P.M. showed the resident refused; no documentation to show extra nourishment was provide, or that the resident had refused, as per the care plan.
Review of the resident's Significant Change MDS, dated [DATE], showed the following:
-Cognitively intact;
-Received dialysis while a resident;
-Weight: 135 pounds;
-Weight loss of 5% or more in the last month or loss of 10% or more in the last six months, not on a physician-prescribed weight loss regimen.
Review of the resident's meal intake record, dated 03/08/25 (dialysis day), showed at 9:56 A.M. 1-25% consumed.
Review of the resident's progress notes, dated 03/08/25, showed at 10:55 A.M., the resident left for dialysis.
Review of the resident's meal intake record, dated 03/08/25 (dialysis day), showed at 2:20 P.M. not available.
Review of the resident's progress notes, dated 03/08/25, showed at 5:25 P.M., the resident returned from dialysis.
Review of the resident's meal intake record, dated 03/08/25 (dialysis day), showed at 5:39 P.M. refused; no documentation to show extra nourishment was provide, or that the resident had refused, as per the care plan.
Review of the resident's MAR, dated March 2025, showed the resident refused his/her Health Shake on 03/09/25.
Review of the resident's weight record, dated 03/10/25, showed the resident weighed 131.3 pounds.
Review of the resident's medical record showed no documentation the facility evaluated the care plan to determine if current interventions were being implemented and effective per the facility policy.
Review of the resident's progress notes, dated 03/11/25 at 9:25 A.M., showed the resident left for dialysis.
Review of the resident's meal intake record, dated 03/11/25 (dialysis day), showed the following:
-At 4:15 P.M., 25-50% consumed;
-At 4:17 P.M. not applicable.
Review of the resident's meal intake record, dated 03/13/25 (dialysis day), showed at 9:57 A.M., 25-50% consumed.
Review of the resident's progress notes dated 03/13/25 at 11:06 A.M. showed the following:
-Dietary manager received a call from the resident's dialysis nurse;
-Dialysis nurse said that resident was okay to eat what he/she would like with his/her weight loss and not to add salt to any foods.
Review of the resident's physician's orders, dated 03/13/25, showed an order for Remeron (anti-depressant medication) 15 milligrams (mg) by mouth at bedtime for depression, appetite stimulant.
Review of the resident's SNAR report dated 03/13/25 showed the following:
Intake:
-Percentage of meals: 25%;
-Percentage of snacks: 25%;
Order changes: Resident recently began dialysis, resident had not felt well this last month related to poor kidney function;
Responsible party and physician notified: Resident with new orders for Remeron 15 mg at bedtime for depression and appetite stimulant.
Review of the resident's meal intake record, dated 03/13/25 (dialysis day), showed at 2:30 P.M. not available.
Review of the resident's progress notes, dated 03/13/25 at 4:26 P.M., showed the resident returned from dialysis.
Review of the resident's meal intake record, dated 03/13/25 (dialysis day), showed at 6:30 P.M. 0 percent (%); no documentation to show extra nourishment was provide, or that the resident had refused, as per the care plan.
Review of the resident's MAR, dated March 2025, showed the resident refused his/her Health Shake with breakfast on 03/15/25.
Review of the resident's meal intake record, dated 03/15/25 (dialysis day) at 4:51 P.M., the resident consumed 25-50%.
Review of the resident's MAR, dated March 2025, showed the resident refused his/her Health Shake with breakfast on 03/16/25 and 03/17/25.
Review of the resident's weight record, dated 03/17/25, showed the resident weighed 131.1 pounds (weight loss of 20.8 pounds or 13% in three months).
Review of the resident's progress notes dated 03/17/25 at 8:57 A.M. showed the resident was offered medications (including Health Shake) and refused, charge nurse made aware.
Review of the resident's care plan meeting note, dated 03/17/25, showed the following:
Dietary review:
-Resident is on a regular renal precautions diet. Resident's dialysis nurse, resident and family suggests resident eats what he/she would like for now because of weight loss;
-No documentation the resident's food and beverage preferences had been reviewed with the resident.
Observation on 03/18/25 showed the following:
-At 9:43 A.M., in the resident's room, showed staff provided morning cares and transferred the resident to his/her wheelchair. Certified Nurse Aide (CNA) P offered the resident a nutritional supplement and the resident refused;
-CNA P did not offer the resident a snack or meal prior to leaving for dialysis;
-At 10:00 A.M., staff pushed the resident in his/her wheelchair to the door. The resident left the facility with transportation to dialysis.
Review of the resident's meal intake record dated 03/18/25 (dialysis day) showed the following:
-At 10:51 A.M. 75-100% consumed;
-At 1:26 P.M. refused; (this was not accurate as the resident was at dialysis).
Observation on 03/18/25 at 4:04 P.M., in the resident's room, showed the following:
-The resident sat in his/her wheelchair;
-CNA P and CNA Q assisted the resident into bed;
-The resident said he/she was starving;
-CNA P said he/she sent the resident's lunch tray back and ordered the resident's supper tray;
-The resident asked CNA Q for a piece of homemade garlic bread kept at the bedside;
-There were apples on the resident's bedside table (brought in by the resident's family);
-CNA Q gave the resident a piece of garlic bread which the resident immediately consumed.
Review of the resident's meal intake record dated 03/18/25 (dialysis day) showed at 6:38 P.M. 51-75% consumed.
Review of the resident's care plan, revised 03/19/25, showed the following:
-On 03/13/25, Remeron 15 mg at bedtime for depression, appetite stimulant;
-Resident currently monitored by SNAR.
During an interview on 03/18/25 at 4:14 P.M., 03/19/25 at 12:41 P.M. and 03/20/25 at 8:45 A.M., the resident said the following:
-Facility staff do not offer him/her a snack or meal prior to going to dialysis;
-He/She would be willing to take a snack or sandwich with him/her to eat before or after dialysis;
-He/She can't eat during dialysis;
-He/She was starving when he/she returned to the facility after dialysis;
-He/She was the lowest weight he/she has ever been and he/she needed to gain weight;
-Staff do not ask him/her what he/she wants for his/her meals.
During an interview on 03/18/25 at 9:59 A.M. and 4:14 P.M., CNA P said the following:
-The resident had lost weight;
-He/She doesn't know if dietary sends the resident lunch or a sandwich to take with him/her on dialysis days;
-He/She usually saves the resident's lunch tray and heats it up when the resident returns from dialysis;
-The resident often refused to eat;
-Nursing staff notify dietary staff if the resident requests an alternative to the main meal;
-He/She tried to send a nutritional supplement with the resident to dialysis but the resident often refused.
During an interview on 03/20/25 at 2:38 P.M., CNA S said the following:
-The Certified Medication Technician (CMT) gives the nutritional supplements;
-CNA staff was responsible for documenting meal intake in the computer;
-If the resident refuses to eat, staff should document in the computer and tell the nurse;
-He/She did not know if the resident had lost weight;
-Staff should always make sure the resident has breakfast on dialysis days and offer a snack and drink before he/she leaves;
-The resident was very picky;
-Staff should let the nurse know if the resident refused to take a snack to dialysis.
During an interview on 03/20/25 at 2:36 P.M., CMT B said the following:
-The resident always refused health shakes;
-He/She documented refusals in the MAR and reports to the nurse.
During an interview on 03/19/25 at 7:30 A.M., Licensed Practical Nurse (LPN) C said the following:
-Staff was responsible for documenting meal intake;
-The resident had lost weight and his/her intake was poor;
-The CMT should notify him/her if the resident refused nutritional supplements.
During an interview on 03/18/25 at 8:41 P.M. and 03/20/25 at 1:24 P.M., the Dietary Manager said the following:
-The resident was on dialysis and had a care plan meeting yesterday (3/17/25);
-Transportation picks the resident up at 9:30 A.M. and he/she was supposed to be ready to start dialysis at 11:00 A.M.;
-She was unsure what time the resident got back from dialysis;
-The residentreceivedd breakfast before he/she left for dialysis;
-The resident had apples and other snacks in his/her room provided by his/her family, that he/she can take with him/her to dialysis;
-She was unsure if dietary staff made a lunch to take with him/her to dialysis;
-The Registered Dietitian visited the facility once a month;
-There was a SNAR meeting once a week. The Director of Nursing/MDS Coordinator and she talk about residents with weight loss and interventions to prevent further weight loss;
-The resident used to come to the dining room and order his/her food, but now he/she ate in his/her room;
-Dietary does not have a list of foods the resident and other residents won't eat or dislike;
-Dietary only has a list of resident allergies;
-When a resident was admitted , dietary completes an assessment including food likes and dislikes; this was only done on admission;
-The resident was at risk for impaired nutritional status and weight loss;
-She did not know how long the resident had been losing weight;
-Interventions in place to prevent further weight loss were medication to stimulateappetitee and the CMTs give the resident a nutritional supplement;
-She did not know if the resident was drinking the nutritional supplement;
-The resident refused meals quite a bit, staff should offer alternatives;
-Most of the time the resident refused to take anything with him/her to dialysis;
-She asked dietary staff if they were sending a meal or snack with the resident on dialysis days, sometimes they do, sometimes they don't.
During an interview on 03/20/25 at 4:40 P.M., the Director of Nursing said the following:
-The resident had experienced weight loss;
-The resident has not been feeling well because his/her kidney function was poor and he/she started dialysis;
-She would expect staff to offer the resident a meal or snack prior to going to dialysis;
-Staff should encourage food and supplements;
-The resident was able to tell staff his/her food likes and dislikes;
-If the resident refused supplements, she would expect the charge nurse and physician to be notified;
-Staff should also offer alternative meals or supplements if the resident's intake was poor.
During an interview on 04/02/25 at 10:16 A.M., the Registered Dietitian said the following:
-She was aware the resident had experienced weight loss;
-She does not participate in the SNAR meetings;
-She mainly works directly with the Dietary Manager in regards to weight loss;
-Staff should document meal intake;
-Staff should offer the resident a meal or snack prior to leaving for dialysis and document if the resident refused;
-Dietary staff should revisit resident food preferences if a resident is experiencing weight loss;
-She was not aware the resident was refusing health shakes.
During an interview on 04/02/25 at 10:22 A.M., the resident's physician said he would expect staff to notify the Registered Dietitian if the resident continued to lose weight. He thought the facility was notifying the Registered Dietitian regarding the resident's weight loss. He was aware of the resident's weight loss and refusals of meals/supplements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, staff failed to follow facility policy for required components for dialysis treatments (a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, staff failed to follow facility policy for required components for dialysis treatments (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) and failed to perform and document assessments for one of one resident sampled (Resident #39) who received dialysis. The facility also failed to provide Resident #39 with services consistent with professional standards of practice by failing to assess the resident's dialysis access site for signs and symptoms of infection before and after dialysis treatments. The facility census was 47.
Review of the facility policy titled Hemodialysis, dated 2024 showed the following:
-This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis;
-The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of care. This will include:
-The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility;
-Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions and using appropriate infection control practices;
-Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services;
-3. The facility will coordinate and collaborate with the dialysis facility to assure that:
d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by facility and dialysis staff;
-4. The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes;
-5. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to:
a. Timely medication administration (initiated, held or discontinued) by the facility and/or dialysis facility;
b. Physician/treatment orders, laboratory values, and vital signs;
d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered;
g. Changes and/or declines in condition unrelated to dialysis;
-8. The nurse will monitor and document the status of the resident's access site upon return form the dialysis treatment to observe for bleeding or other complications;
-9. The facility will communicate with the dialysis facility, attending physician and/or nephrologist any significant weight changes, nutritional concerns, medication administration or withholding of certain medications prior to the dialysis treatment and document such orders;
-13. The facility will ensure that the physician's orders for dialysis include:
a. The type of access for dialysis and location;
b. The dialysis schedule;
c. The nephrologist (physician who specializes in the diagnosis, treatment, and prevention of kidney diseases) name and phone number;
d. The dialysis facility name and phone number;
e. Transportation arrangements to and from the dialysis facility;
f. Any medication administration or withholding of specific medications prior to dialysis treatments;
-16. Residents with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled.
Review of the agreement between the dialysis clinic and the facility, signed 04/08/24 showed the following:
Responsibilities of the facility:
-Facility staff will make an assessment of each resident's physical condition and determine whether the resident is stable enough to be dialyzed on an outpatient basis;
-If it is determined that the resident is sufficiently stable, this assessment will be communicated to the facility's nurse manager or his or her designee;
-This assessment and communication will occur prior to each and every transfer of a resident to the dialysis clinic regardless of the number of times any particular resident may be transferred or dialyzed.
1. Review of Resident #39's physician's orders, dated February 2025, did not include an order for dialysis.
Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/19/25, showed the following:
-Cognitively intact;
-Diagnosis of end stage renal disease (also known as kidney failure, a condition in which the kidneys have permanently lost most of their ability to function) and hyperkalemia (high potassium levels).
Review of the resident's progress notes dated 02/19/25 at 3:43 P.M., showed the resident was scheduled for a procedure for dialysis perm cath (a long, flexible tube inserted into a blood vessel in the neck or chest to provide access for hemodialysis) placement on 02/26/25.
Review of the resident's progress notes, dated 02/26/25, showed the following:
-At 7:00 A.M. the resident left with family member for dialysis access procedure;
-At 3:34 P.M. the resident returned from dialysis perm cath procedure with the family member. Dressing dry and intact. Instructions not to change dressing as resident will be going to dialysis three times a week and the dialysis clinic will take care of dressing changes.
Review of the resident's progress notes dated 02/27/25 showed the following:
-At 9:20 A.M. the resident left with family for dialysis:
-At 1:43 P.M. the resident returned from dialysis.
Review of the facility dialysis communication binder showed it did not include a dialysis communication form dated for 02/27/25 thatincludedg documentation of an assessment or communication prior to the resident's transfer for dialysis as the facility policy directed. Further review showed no documentation of an assessment after the resident returned from his/her dialysis as facility policy directed.
Review of the resident's medical record, dated 02/27/25, showed it did not include a dialysis communication form including documentation of an assessment or communication prior to the resident's transfer for dialysis as the facility policy directed. Further review showed no documentation of an assessment after the resident returned from his/her dialysis as the facility policy directed.
Review of the resident's February 2025 medication administration record (MAR) and treatment administration record (TAR) showed no documentation assessments were completed prior to or after the resident's dialysis appointments.
Review of the resident's physician's orders, dated March 2025, did not include an order for dialysis.
Review of the resident's progress notes dated 03/01/25 at 11:12 A.M. showed the resident left with transportation for dialysis.
Review of the resident's dialysis communication form, held in the facility dialysis binder, dated 03/01/25 showed the following:
Post-dialysis information:
-Shunt/Catheter location/status: left blank;
-Catheter dressing intact: left blank;
-Bleeding: left blank;
-General condition of resident: left blank;
-Vital signs: left blank.
(Staff had not completed the assessment after the resident returned from his/her dialysis appointment as the facility policy instructed).
Review of the resident's medical record, dated 03/01/25, showed it did not include documentation of an assessment after the resident returned from his/her dialysis as the facility policy directed.
Review of the resident's progress notes, dated 03/04/25, the following:
-At 8:11 A.M. the resident refused medications, charge nurse made aware;
-At 3:06 P.M. resident out of the facility for dialysis.
Review of the resident's dialysis communication form dated 03/04/25 showed the following:
Pre-dialysis information:
-Medications administered prior to dialysis: left blank;
-Meal/snack sent: left blank;
-Shunt/Catheter location/status: left blank;
-Vital signs: left blank;
Post-dialysis information:
-Shunt/Catheter location/status: left blank;
-Catheter dressing intact: left blank;
-Bleeding: left blank;
-General condition of resident: left blank;
-Vital signs: left blank.
(Staff had not completed the assessment or communication form prior to the resident's dialysis and had not completed the assessment after the resident returned from his/her dialysis appointment as the facility policy instructed)
Review of the resident's medical record, dated 03/04/25, showed it did not include a dialysis communication form including documentation of an assessment or communication prior to the resident's transfer for dialysis or documentation of an assessment after the resident returned from his/her dialysis as the facility policy directed.
Review of the resident's care plan, revised 03/05/25, showed the following:
-The resident received hemodialysis three times a week: Tuesday/Thursday/Saturday;
-Dressing to internal jugular catheter (IJC) completed by dialysis clinic three times a week;
-The resident has a right IJC used for dialysis only;
-Please fill out the dialysis communication form on dialysis days;
-Report any of the following to the dialysis clinic immediately: dressing soaked with any type of discharge from catheter site, any foul smell from catheter site, blood soaked dressing, uncapped or unclamped catheter, fever, chills or pain, redness or swelling around the catheter site.
Review of the resident's progress notes, dated 03/06/25 at 9:18 A.M., showed the following:
-IJC remains intact to right side of upper chest;
-Dressing to area clean, dry and intact;
-Dressings are being changed while at dialysis.
Review of the resident's progress notes dated 03/06/25 at 11:08 A.M. showed the resident left the facility at this time with transportation to dialysis clinic.
Review of the resident's dialysis communication form, dated 03/06/25, showed the following:
Pre-dialysis information:
-Medications administered prior to dialysis: blank;
-Vital signs: blank;
Post-dialysis information:
-Shunt/Catheter location/status: blank;
-Catheter dressing intact: blank;
-Bleeding: blank;
-General condition of resident: blank;
-Vital signs: blank.
(Staff had not completed the assessment or communication form prior to the resident's dialysis and had not completed the assessment after the resident returned from his/her dialysis appointment as the facility policy instructed)
Review of the resident's medical record, dated 03/06/25, showed it did not include a dialysis communication form including documentation of an assessment or communication prior to the resident's transfer for dialysis or documentation of an assessment after the resident returned from his/her dialysis as the facility policy directed.
Review of the resident's Significant Change MDS, dated [DATE], showed the following:
-Cognitively intact;
-End stage renal disease;
-Received dialysis while a resident.
Review of the resident's progress notes, dated 03/08/25, showed the following:
-At 10:55 A.M. the resident left for dialysis;
-At 5:25 P.M. the resident returned from dialysis.
Review of the resident's dialysis communication form, dated 03/08/25, showed the following:
Pre-dialysis information:
-Medications administered prior to dialysis: blank;
-Temperature: blank;
-Pain: blank;
Post-dialysis information:
-Shunt/Catheter location/status: blank;
-Catheter dressing intact: blank;
-Bleeding: blank;
-General condition of resident: blank;
-Vital signs: blank.
(Staff had not completed the assessment or communication form prior to the resident's dialysis and had not completed the assessment after the resident returned from his/her dialysis appointment as the facility policy instructed)
Review of the resident's medical record, dated 03/08/25, showed it did not include a dialysis communication form including documentation of an assessment or communication prior to the resident's transfer for dialysis or documentation of an assessment after the resident returned from his/her dialysis as the facility policy directed.
Review of the resident's progress notes, dated 03/11/25 at 9:25 A.M., showed the resident left for dialysis.
Review of the resident's dialysis communication form, dated 03/11/25, showed the following:
Pre-dialysis information:
-Meal/snack sent: blank;
-Shunt/Catheter location/status: blank;
Post-dialysis information:
-Shunt/Catheter location/status: blank;
-Catheter dressing intact: blank;
-Bleeding: blank;
-General condition of resident: blank;
-Vital signs: blank.
(Staff had not completed the assessment or communication form prior to the resident's dialysis and had not completed the assessment after the resident returned from his/her dialysis appointment as the facility policy instructed)
Review of the resident's medical record, dated 03/11/25, showed it did not include a dialysis communication form including documentation of an assessment or communication prior to the resident's transfer for dialysis or documentation of an assessment after the resident returned from his/her dialysis as the facility policy directed.
Review of the resident's dialysis communication form, dated (Thursday) 03/13/25, showed the following:
Pre-dialysis information:
-Medications administered prior to dialysis: blank;
-Vital signs: blank;
-Meal/Snack sent: blank.
(Staff had not completed the assessment or communication form prior to the resident's dialysis as the facility policy instructed)
Review of the resident's progress notes, dated 03/13/25 4:26 P.M., showed the resident returned from dialysis.
Review of the resident's medical record, dated 03/13/25, showed it did not include a dialysis communication form including documentation of an assessment or communication prior to the resident's transfer for dialysis as the facility policy directed.
Review of the resident's dialysis communication form, dated 03/15/25, showed the following:
Pre-dialysis information:
-Meal/snack sent: blank;
-Vital signs: blank.
(Staff had not completed the assessment or communication form prior to the resident's dialysis as the facility policy instructed)
Review of the resident's progress notes, dated 03/15/25 at 5:37 P.M., showed the following:
-The resident was out to dialysis earlier today;
-Dialysis access bandage dry and intact.
Review of the resident's medical record, dated 03/15/25, showed it did not include a dialysis communication form including documentation of an assessment or communication prior to the resident's transfer for dialysis as the facility policy directed.
Review of the resident's dialysis communication form, dated 03/18/25, showed the following:
Pre-dialysis information:
-Meal/Snack sent: blank;
Post-dialysis information:
-Shunt/Catheter Location/Status: blank;
-Catheter dressing intact: blank;
-Bleeding: blank;
-General condition of resident: blank;
-Vital signs: blank.
(Staff had not completed the assessment after the resident returned from his/her dialysis appointment as the facility policy instructed).
Review of the resident's medical record, dated 03/18/25, showed it did not include a dialysis communication form including documentation of an assessment after the resident returned from his/her dialysis as the facility policy directed.
Review of the resident's March 2025 MAR and TAR showed no documentation of assessments being completed prior to or after the resident's dialysis appointments.
During an interview on 03/18/25 at 9:43 A.M. and 03/20/25 at 8:12 A.M., the resident said the following:
-He/She recently (within the last few weeks) began dialysis at a nearby dialysis clinic;
-He/She goes to dialysis Tuesdays, Thursdays and Saturdays from mid morning to mid afternoon;
-He/She received dialysis through an access in his/her right chest;
-Facility staff did not check or assess his/her dialysis access site, only the dialysis staff;
-He/She would be willing to take a snack or sandwich/bag lunch with him/her to eat on the way to dialysis or on the way back.
During an interview on 04/01/25 at 9:08 A.M., Licensed Practical Nurse (LPN) C said the following:
-He/She had not received education regarding care for a resident with dialysis;
-The dialysis communication sheet should be filled out prior to and after dialysis and placed in the dialysis communication binder;
-The dialysis communication binder was used to communicate with the dialysis clinic;
-The resident's dialysis access site should be assessed and the assessment should be documented on the dialysis communication form;
-Staff should offer the resident a snack or shake prior to going to dialysis and notify the nurse if the resident refused, this information should also be documented on the dialysis communication form.
During an interview on 03/20/25 at 8:15 A.M. Registered Nurse (RN) N said staff should fill out the predialysis information on the dialysis communication form prior to dialysis and send the dialysis communication book with the resident to dialysis.
During an interview on 3/20/25 at 4:40 P.M. the Director of Nursing said the following:
-The resident should have a physician's order for dialysis treatments;
-The nephrologist gave an order for dialysis, she would expect the charge nurse to put the order in the computer;
-She had provided training to staff regarding care of residents receiving dialysis;
-Staff should document when the resident goes to dialysis and his/her condition before and after dialysis;
-This information should be documented in the resident's record and also in the dialysis communication binder;
-Staff should also assess the resident's dialysis access site every shift and document the assessment;
-Staff should leave the dialysis access site dressing intact but assess every shift;
-She would expect nursing staff to offer a lunch meal or snack prior to leaving for dialysis;
-If the resident refused a meal or snack prior to dialysis, she would expect staff to document the refusal.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
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 convey the remaining resident balance to the state or the probate j...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to convey the remaining resident balance to the state or the probate jurisdiction administering the resident's estate within 30 days of death for eight residents (Residents #109, #103, #100, #102, #107, #106, #108, and #101), and failed to return resident funds to two discharged residents (Residents #105 and #104), within five days following discharge. The facility failed to send an accounting of the funds for Resident #109, who received Medicaid payment for his/her stay, to the state and planned to apply the remaining balance to the outstanding balance owed to the facility. The facility census was 47.
Review of the facility's undated policy, Conveyance of Resident Funds Upon Discharge, Eviction, or Death, showed the following:
-Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate, in accordance with State law.
-For any resident with a personal fund deposited with the facility:
-The facility will convey the resident's funds, from the resident's personal fund account deposited in the facility, to the individual or probate jurisdiction administering the resident's estate as provided by State law, within 30 days of the resident's discharge, eviction, or death.
-The facility will convey a final accounting of the resident's personal fund account to the individual or probate jurisdiction administering the resident's estate as provided by State law, within 30 days of the resident's discharge, eviction, or death.
-The facility will keep records to demonstrate accountability of all resident funds deposited within the facility and conveyance of all resident funds upon the discharge, eviction, or death of residents.
1. Review of Resident #109's electronic medical record showed the resident expired on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $2,679.98.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's pay source was Medicaid (effective [DATE]). The resident's remaining balance was to be transferred to the facility to pay an outstanding balance.
During an interview on [DATE] at 3:00 P.M. and 3:46 P.M., the Business Office Manager said the resident's pay source (private pay versus Medicaid) was being evaluated through legal proceedings so the facility had not done anything with the resident's trust fund balance. The facility planned to use the resident's trust fund balance to pay for his/her outstanding balance owed to the facility.
2. Review of Resident #103's electronic medical record showed the resident expired on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $2,159.15
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's pay source was Medicaid. The resident's personal funds report was sent to the state on [DATE].
3. Review of Resident #100's electronic medical record showed the resident expired on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $1,925.56.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's pay source was private pay. The resident's remaining balance was to be transferred to the facility to pay an outstanding balance.
During an interview on [DATE] at 3:00 P.M. and 3:46 P.M., the Business Office Manager said the resident's pay source (private pay versus Medicaid) was being evaluated through legal proceedings so the facility had not done anything with the resident's trust fund balance. The facility planned to use the resident's trust fund balance to pay for his/her outstanding balance owed to the facility.
4. Review of Resident #102's electronic medical record showed the resident expired on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $126.57.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's pay source was Medicaid. The resident's personal funds report was sent to the state on [DATE].
5. Review of Resident #107's electronic medical record showed the resident expired on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $50.00.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's pay source was private pay. The resident's remaining balance was to be transferred to the facility to pay an outstanding balance.
6. Review of Resident #106's electronic medical record showed the resident expired on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $40.10.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's pay source was Medicaid. The resident's personal funds report was sent to the state on [DATE].
7. Review of Resident #108's electronic medical record showed the resident expired on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $34.67.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's pay source was Medicaid. The resident's personal funds report was sent to the state on [DATE].
8. Review of Resident #105's electronic medical record showed the resident discharged to home on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $20.00.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's remaining balance was refunded to the resident on [DATE].
9. Review of Resident #104's electronic medical record showed the resident transferred to another facility on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $14.72.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's remaining balance was refunded to the resident on [DATE].
10. Review of Resident #101's electronic medical record showed the resident expired on [DATE].
Review of the facility's current balance report for the resident funds account, dated [DATE], showed the resident had a balance of $3.54.
Review of an untitled, undated document, provided by the business office manager on [DATE], showed the resident's pay source was private pay. The resident's remaining balance was to be transferred to the facility to pay an outstanding balance.
11. During interview on [DATE] at 3:00 P.M. and 3:36 P.M., the Business Office Manager said the following:
-The facility wrote checks from the resident trust fund today to the families of the residents who were deceased and did not have outstanding balance at the facility;
-The facility wrote a check to the facility out of the resident trust fund for the deceased residents with outstanding balances owed to the facility;
-The facility completed an accounting of funds and sent it to the state for the Medicaid residents with balances in the resident trust fund;
-She did not know prior to today what she was to do with the discharged /deceased residents' funds.
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 interview and record review, the facility failed to provide the pneumococcal vaccine (a vaccine that can protect agains...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the pneumococcal vaccine (a vaccine that can protect against pneumococcal disease), as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines and recommendations for three residents (Residents #37, #3 and #21), in a review of 14 sampled residents. The facility census was 47.
Review of the facility policy, Pneumococcal Vaccine, dated October 2024, showed the following:
-It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations;
-Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized.
-The type of pneumococcal vaccine (PCV15, PCV20, PCV21 or PPSV23) offered will depend upon the recipient's age, having certain risk conditions, and previously received pneumococcal vaccines, in accordance with current CDC guidelines and recommendations.
Review of the CDC guidelines for pneumococcal vaccination, dated 11/24/24, showed the following:
-For adults age [AGE] years or older who have not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21;
-If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak);
-Previously received only PCV7: follow the recommendation above;
-Previously received only PCV13: 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PCV13 dose;
-Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose;
-If PCV15 is used, no additional PPSV23 doses are recommended;
-Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 or 1 dose PCV21 at least 5 years after the last pneumococcal vaccine dose;
-Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose.
1 Review of Resident #3's undated face sheet showed the following:
-The resident was responsible for self for decision making;
-Diagnoses included paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic kidney disease Stage III (mild to moderate kidney damage), and heart disease.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/25/24, showed the following:
-Cognition intact;
-Pneumococcal vaccine up to date.
Review of the resident's undated facility immunization record showed the following:
-The resident was over [AGE] years of age;
-Prevnar 13 administered on 08/18/2016 (after age [AGE]);
-PPSV23 administered on 10/19/2018 (after age [AGE]);
-No documentation that PCV20 or PCV21 were administered, offered or declined;
-No documentation the resident had a medical contraindication to the vaccine;
(The resident was not up to date per CDC guidelines).
During an interview on 03/17/25 at 12:35 P.M., the resident said he/she thought his/her pneumococcal vaccination was up to date and if it wasn't, he/she would want to receive the recommended vaccine.
2. Review of Resident #21's undated face sheet showed the following:
-The resident was responsible for self for decision making;
-Diagnoses included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), Type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar (the amount of sugar in the blood) and using it for energy), and heart disease.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition intact;
-Pneumococcal vaccine not up to date; not offered.
Review of the resident's undated facility immunization record showed the following:
-The resident was over [AGE] years of age;
-No documentation that a pneumococcal vaccine was administered, offered or declined;
-No documentation the resident had a medical contraindication to the vaccine;
(The resident was not up to date per CDC recommendations.)
During an interview on 03/20/25 at 12:00 P.M., the resident said that if he/she was due to have a pneumococcal vaccination, he/she would want to receive the vaccination.
3. Review of Resident #37's quarterly MDS dated [DATE] showed the following:
-The resident was over [AGE] years of age;
-Severely impaired cognition;
-Diagnoses of heart failure and chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe);
-Pneumococcal vaccine up to date.
Review of the resident's undated facility immunization record showed the following:
-Prevnar 13 administered in 2014 (after age [AGE]);
-PCV23 administered 3/2016 (after age [AGE]);
-No documentation of PCV20 or PCV21 administered, offered or declined;
-No documentation the resident had a medical contraindication to the vaccine.
(The resident was not up to date per CDC recommendations).
During an interview on 04/01/25 at 8:05 A.M., the resident's responsible party said the following:
-He/She did not know if the resident is up to date with his/her pneumonia vaccine;
-He/She did not recall the facility offering the pneumonia vaccine;
-He/She wanted the resident to be up to date with his/her pneumonia vaccinations.
During the interview on 03/19/25 at 10:15 A.M., the Infection Preventionist (IP) said if a resident refused a vaccine, the resident or their power of attorney signed a refusal and the facility provided them education from CDC on the vaccine.
During an interview on 3/20/25 at 4:40 P.M., the Director of Nurses said pneumococcal vaccines should be given or at least offered and documented as such per CDC guidelines and per facility policy.
During an interview on 3/20/25 at 5:05 P.M., the Administrator said pneumococcal vaccines should be given, or at least offered and documented as such per CDC guidelines and per facility policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the range hood was free of a buildup of grease a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the range hood was free of a buildup of grease and debris, failed to ensure food items were closed/sealed, discarded when expired, and stored according to the manufacturer's label; failed to ensure the wall behind the fryer was free of a buildup of grease; and failed to ensure one refrigerator in the kitchen was equipped with a thermometer. The facility census was 47.
1. Review of the undated facility policy, Kitchen Hood Inspection and Cleaning, showed the following:
-A safe and healthful work environment will be provided for all employees, residents and visitors. Pursuant to this end, the kitchen hood exhaust system will be properly cleaned and maintained in order to support the functioning of the kitchen hood fire suppression system;
-The facility maintenance director and/or his designee will ensure the kitchen [NAME] fire suppression system is properly inspected and maintained;
-The kitchen hood visual inspection will be completed monthly by the facility maintenance director or his designee;
-If the hood exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system will be cleaned by a properly trained, qualified and certified person(s) acceptable to the authority having jurisdiction.
Observation on 3/17/25 at 10:56 A.M. showed the range hood sticker on the hood exterior showed the hood had previously been cleaned in January 2025 and was due again for cleaning in July 2025.
Observation on 3/17/25 at 10:57 A.M. showed the range hood had five baffle filters. A buildup of heavy yellow/brown grease was visible on three of five baffle filters. The range hood protected the double fryer, and a six-burner stove/griddle.
During an interview on 3/17/25 at 10:55 A.M., Dietary [NAME] O said dietary staff don't clean the filters, nor does maintenance staff. A professional company comes from the city to clean the filters, but he/she was unsure how often the cleaning was conducted.
2. Review of the undated facility policy, Date Marking for Food Safety, showed the following:
-The facility adheres to a marking system to ensure the safety of ready-to-eat, time/temperature control for safety food;
-The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded;
-The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest;
-The head cook or designed shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly.
Observation on 3/17/25 at 9:34 A.M. and on 3/18/25 at 8:05 A.M. of the items stored on a tray above the stove (not in use) showed the following:
-The lid to an 18-ounce container of ground cinnamon was open and not sealed;
-The lid to a 26-ounce container of steak seasoning was open and not sealed;
-The lid to a 38-ounce of select seasoning salt was open and not sealed;
-The lid to an 18-ounce container of ground black pepper and was not sealed.
Observation on 3/17/25 at 9:49 A.M. and on 3/18/25 at 8:05 A.M. inside the dry storage room in the kitchen showed the following:
-The lid on a 15-ounce container of ground mustard was open and not sealed;
-The lid on a 16-ounce container of baking soda was open and not sealed.
Observation on 3/17/25 at 10:44 A.M. inside the clean utility room on the [NAME] Hall, showed the following items in the refrigerator:
-One 5.3-ounce container of non-fat yogurt had an expiration date of 2/23/25 and was not labeled with a resident name or room number;
-Two 6-ounce containers of low-fat strawberry banana yogurt had expiration dates of 3/9/25. One container was labeled JA and the other container was labeled DA;
-One 20-ounce jar of concord grape jelly sat on top of the microwave near the refrigerator. The label on the jar indicated Refrigerate after opening. The jar was dated 3/11/25 and was not stored in the refrigerator.
Observation on 3/17/25 at 10:52 A.M., showed inside the main dining room on the beverage counter a 20-ounce jar of concord grape jelly sat on top of the microwave near the refrigerator. The label on the jar indicated Refrigerate after opening. The jar was dated 3/11/25 and was not stored in the refrigerator.
Observation on 3/18/25 at 8:23 A.M. inside the west clean utility room, a 20-ounce jar of grape jelly sat out on top of the microwave and was not stored in the refrigerator.
3. Observation on 3/17/25 at 9:33 A.M. and on 3/18/25 at 8:05 A.M. showed the metal wall behind the double fryer had a heavy buildup of clear grease.
During an interview on 3/18/25 at 8:41 A.M. the Dietary Manager, said the following:
-Staff (cooks and aides) were assigned daily, weekly and monthly tasks;
-Walls should be cleaned weekly by the cook;
-An outside company that cleaned the range hood grease also cleaned the wall behind the fryer;
-Prepared food items were good for three days and should be discarded after three days. Items stored in refrigerators should be checked daily by the cooks and aides;
-Spice lids should be closed when not in use;
-Grape jelly should be stored in the refrigerator when not in use;
-Housekeeping checked the hall refrigerators on east/west for expiration dates and would throw away expired items when found;
-Beverage fridge in kitchen did not have a thermometer inside and should have one;
-Yogurt should be discarded if expired past manufacturer's expiration date;
-Aides/cooks should take the baffle filters out of hood weekly and run them through the dishwasher and put them back in the hood.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to use appropriate infection control procedures for hand ...
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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 use appropriate infection control procedures for hand hygiene to prevent the spread of bacteria or other infectious causing contaminates for two residents (Resident #39 and Resident #300) in a review of 14 sampled residents and failed to utilize the appropriate personal protective equipment (PPE), including gowns, when providing care for residents who required Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) for one sampled resident (Resident #39). The facility also failed to ensure that there was a water management program in place to reduce the risk of legionellosis (any disease caused by Legionella - a bacteria which people can breathe in without knowing, sometimes causing infection in the lungs)) in the facility. The facility census was 47.
Review of the facility's undated Hand Hygiene Policy showed the following:
-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility;
-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;
-Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table;
-Alcohol-based rub with 60 to 90% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating and after using the restroom;
-The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves;
-Bar soap is approved for a resident's personal use only. Keep bar soap clean and dry in protective containers (i.e. plastic case or bag);
-Liquid soap reservoirs must be discarded when empty. If refillable, dispensers must be emptied, cleaned, rinsed and dried according to manufacturer instructions;
-Use lotions and creams to prevent and decrease skin dryness. Use only hand lotions approved by the facility because they won't interfere with alcohol based hand rubs (ABHR's).
Review of Infection Control Guidelines for Long-Term Care Facilities, emphasis on Body Substance Precautions, dated January 2005, showed the following:
-Handwashing remains the single most effective means of preventing disease transmission;
-Wash hands often and well, paying particular attention to around and under fingernails and between the fingers;
-Wash hands whenever they are soiled with body substances, before food preparation, before eating, after using the toilet, before performing invasive procedures and when each resident's care is completed;
-Gloves must be changed between residents and between contacts with different body sites of the same resident.
1. Review of Resident #300's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/06/25, showed the following:
-Occasionally incontinent of bowel and bladder;
-Partial/moderate assistance with toileting and personal hygiene;
-Supervision or touching assistance with toilet transfer.
Review of the resident's care plan, revised on 03/14/25 showed the following:
-Needs pericare after incontinence episodes;
-Wears incontinence products, check per facility protocol;
-Requires partial to moderate assistance of one staff member for perineal hygiene.
Observation on 03/19/25 at 5:55 A.M. showed the following:
-With gloves on, Certified Nurse Assistant (CNA) J assisted the resident to a standing position from the toilet, cleaned the resident's perineum with incontinent wipes and removed feces from the resident's skin;
-CNA J placed the soiled wipes in the trash can;
-Without changing his/her soiled gloves, CNA J pulled up the resident's clean incontinence brief and clean pants and assisted the resident to his/her wheelchair, touching the resident's clean items, the resident and the wheelchair with soiled gloves.
Observation on 03/19/25 at 1:15 P.M. showed the following:
-With gloves on, CNA L cleaned the resident's perineum with incontinent wipes, removing urine from the resident's skin; with soiled gloves, CNA L removed incontinent wipes from the package and continued to clean the resident's perineum;
-Without changing his/her soiled gloves, CNA L fastened the resident's clean incontinence brief and pulled up the resident's pants, pivoted the resident to his/her wheelchair, then removed his/her soiled gloves and washed hands;
-CNA L had touched the resident's clean items, the resident and the wheelchair with soiled gloves.
During an interview on 03/19/25 at 1:30 P.M., CNA L said the following:
-When providing pericare, if gloves were visibly soiled, he/she would have changed them before pulling up a clean incontinence brief and pants;
-He/She was not aware he/she should have changed gloves after pericare and before pulling up a resident's pants or touching clean items.
During an interview on 03/20/25 at 1:37 P.M., CNA J said the following:
-When providing personal cares, he/she would use hand sanitizer, put on gloves, clean the resident, remove gloves, use hand sanitizer or wash hands if the resident had been soiled or had a bowel movement before touching clean objects;
-He/She should have removed his/her soiled gloves before touching the resident's clean brief and pants.
2. Review of Resident #39's care plan, revised 03/05/25, showed the following:
-The resident was incontinent of bowel and bladder;
-The resident was dependent and required one staff member for perineal hygiene. Staff does ALL the effort, including perineal hygiene, and adjusting clothing before and after voiding;
-The resident was dependent with all transfers. The resident required assistance of one or two staff to complete the activity of transfers;
-EBP: PPE required for high resident contact care activities. Indication: wounds, indwelling medical device, infection and/or MDRO status.
Review of the resident's Significant Change MDS, dated [DATE], showed the following:
-Cognitively intact;
-End stage renal disease;
-Received dialysis while a resident;
-Always incontinent of bowel and bladder.
Observation on 03/18/25 at 9:35 A.M., outside the resident's room, showed the following:
-A red Centers for Disease Control (CDC) EBP stop sign;
-The sign said everyone must clean their hands, including before entering and when leaving the room;
-Providers and staff must also wear gloves and a gown for dressing, transferring, hygiene, changing briefs or assisting with toileting, and device care or use: central line.
Observation on 03/18/25 at 9:43 A.M., in the resident's room, showed the following:
-An organizer hung on the outside of the resident's door;
-The organizer contained gowns, gloves and masks;
-The resident lay in his/her bed;
-Licensed Practical Nurse (LPN) C and CNA P entered the resident's room;
-LPN C and CNA P performed hand hygiene and applied gloves;
-LPN C and CNA P did not apply gowns;
-CNA P removed the resident's pajama pants;
-CNA P unfastened the resident's incontinence brief and provided front pericare with disposable wipes;
-CNA P and LPN C assisted the resident to roll on his/her left side;
-The resident was incontinent of a medium amount of formed feces;
-CNA P provided rectal pericare with disposable wipes;
-CNA P removed the soiled incontinence brief, placed the brief in the trash, removed his/her gloves and washed his/her hands;
-CNA P applied clean gloves;
-CNA P provided rectal pericare with washcloths and soap;
-Feces was visible on the washcloths;
-CNA P bagged the soiled linens;
-Without changing gloves or washing his/her hands, CNA P picked up the clean incontinence brief and placed the clean brief under the resident's hips;
-LPN C and CNA P (with soiled gloves) assisted the resident to roll back and forth in bed; CNA P touched the resident's legs;
-With the same soiled gloves, CNA P fastened the resident's clean incontinent brief;
-LPN C put clean socks on the resident's feet and pulled clean sweatpants up the resident's thighs;
-With the same soiled gloves, CNA P touched the divider curtain, pushed the curtain back and helped pull up the resident's sweatpants;
-CNA P removed his/her soiled gloves, washed his/her hands and applied clean gloves;
-The resident had a central line present in his/her right chest wall;
-CNA P washed under the resident's arms and applied a clean t-shirt;
-CNA P applied a gait belt around the resident's waist;
-LPN C and CNA P transferred the resident to his/her wheelchair.
Observation on 03/18/25 at 4:04 P.M., in the resident's room, showed the following:
-The resident sat in his/her wheelchair;
-CNA P and CNA Q entered the room;
-CNA P and CNA Q washed their hands and applied gloves;
-CNA P and CNA Q did not apply gowns;
-CNA P applied a gait belt around the resident's waist and transferred the resident to his/her bed;
-CNA P and CNA Q removed the resident's sweatpants and unfastened his/her incontinence brief;
-The resident urinated in his/her incontinent brief after staff had unfastened and lowered it;
-CNA Q provided front pericare;
-CNA Q removed his/her gloves, washed his/her hands and applied clean gloves;
-CNA P rolled the resident to his/her left side, performed rectal pericare and removed the soiled incontinence brief;
-CNA P removed his/her gloves, washed his/her hands and applied clean gloves;
-CNA P and CNA Q applied and fastened a clean incontinence brief;
-CNA P and CNA Q removed gloves, washed hands and exited the resident's room.
During an interview on 04/01/25 at 9:06 A.M., CNA Q said the following:
-He/She had received training regarding EBP;
-A gown and gloves should be worn when providing cares for a resident on EBP.
During an interview on 04/01/25 at 11:09 A.M., CNA P said the following:
-He/She has received both online and in-person training regarding EBP;
-He/She should have worn both a gown and gloves when providing personal care for the resident;
-He/She usually works on the other hall (east hall) and forgot the resident had a central line;
-He/She has received training regarding infection control including hand washing and glove use;
-He/She should change gloves and wash hands after performing pericare prior to touching clean items.
During an interview on 04/01/25 at 9:08 A.M., LPN C said the following:
-He/She received online training regarding EBP;
-Staff should wear both gloves and a gown when providing personal care for the resident.
During an interview on 03/20/25 at 4:40 P.M., the Director of Nursing (DON) said the following:
-She would expect staff to wash hands before and after cares, when soiled and when gloves are changed;
-She would expect staff to change gloves and perform hand hygiene after performing pericare prior to touching clean items;
-She would expect staff to wear EBP as indicated during personal care for Resident #39;
-Staff should wear both gloves and a gown when providing personal care and assisting with transfers for Resident #39.
3. Review of the facility policy, Water Management Program, revised February 2023, showed the following:
-It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens (e.g. pseudomonas, acinetobacter, burkholderia, stenotrophomonas, nontuberculous mycobacteria, and fungi) in the facility's water systems based on nationally accepted standards (e.g. ASHRAE, CDC, EPA);
-A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing;
a. Team members have been educated on the principles of an effective water management program, including how Legionella and other water-borne pathogens grow and spread; Education is consistent
with each team member's role;
b. The water management team has access to water treatment professionals, environmental health specialists, and state/local health officials;
-The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder;
-A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements:
a. Premise plumbing: This includes water system components as described in the documentation of the facility's water system;
b. Clinical equipment: This includes medical devices and other equipment utilized in the facility that can spreadLegionellaa through aerosols or aspiration;
c. At-risk population - this facility's entire population is at risk. High risk areas shall be identified through the risk assessment process. Supporting documentation of any areas or resident population that exhibit greater risk than the general population shall be kept in the water management program binder;
-Data to be used for completing the risk assessment may include, but are not limited to:
a. Water system schematic/description;
b. Legionella environmental assessment;
c. Resident infection control surveillance data (i.e. culture results);
d. Environmental culture results;
e. Rounding observation data;
f. Water temperature logs;
g. Water quality reports from drinking water provider (i.e. municipality, water company);
h. Community infection control surveillance data (i.e. health department data);
-Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder;
-Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. The measures shall be specified in the water management program action plan;
-Testing protocols and control limits will be established for each control measure;
a. Individuals responsible for testing or visual inspections will document findings;
b. When control limits are not maintained, corrective actions will be taken and documented
accordingly;
c. Protocols and corrective actions will reflect current industry guidelines (i.e. ASHRAE, OSHA, CDC, EPA);
-The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program activity for which they are responsible;
-The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness;
-All cases of healthcare-associated legionellosis or other opportunistic waterborne pathogens shall be reported to local/state health officials, followed by an investigation;
a. The Infection Preventionist will investigate all cases of definite healthcare-associated Legionnaires' disease for the source of Legionella;
b. The Infection Preventionist will also investigate for the source of Legionella when two or more possible healthcare-associated Legionnaires' disease are identified;
c. Elements of an investigation may include:
i. Reviewing medical and microbiology records;
ii. Actively identifying all new and recent residents will healthcare-associated pneumonia and testing them for Legionella using both culture of lower respiratory secretions and the Legionella urinary antigen test;
iii. Developing a line list of cases;
iv. Evaluating potential environmental exposures;
v. Performing an environmental assessment;
vi. Performing environmental sampling, as indicated by the environmental assessment;
vii. Subtyping and comparing clinical and environmental isolates;
viii. Decontaminating environmental source(s);
ix. Working with local and/or state health department staff to determine how long heightened disease surveillance and environmental sampling should continue to ensure an outbreak is over;
x. Reviewing and possibly revising the water management program, with input from local and/or state health department staff;
-The facility may utilize outside resources such as microbiologists, environmental health specialists, or state/local health officials for investigations and revising the water management program;
-The facility will conduct an annual review of the water management program as part of the annual review of the infection prevention and control program, and as needed, such as when any of the following events occur:
a. Data review shows control measures are persistently outside of control limits;
b. A major maintenance or water service change occurs (including replacing tanks, pumps, heat exchangers, distribution piping, or water service disruption from the supplier to the building);
c. One or more cases of disease are thought to be associated with the facility's systems, or;
d. Changes occur in applicable laws, regulations, standards, or guidelines;
-In the event of an update to the water management program, the water management team shall:
a. Update the water system schematics/description, associated control points, control limits and pre-determined corrective actions;
b. Train those responsible for implementing and monitoring the updated program;
-Documentation of all the activities related to the water management program shall be maintained with the water management program binder for a minimum of three years;
-The water management team shall report relevant information to the QAPI committee.
Review of the facility water management program binder showed it only included water temperatures and a template of a program to follow. It did not contain documentation that describes the facility's water system, a risk assessment that identified high risk areas or supporting documentation of any areas or resident population that exhibit greater risk than the general population and no documentation of identified control points.
During an interview on 03/19/25 at 10:50 A.M., the Infection Preventionist said the following:
-The Maintenance Director was responsible for the water management program;
-She was not a part of the water management team;
-She had not been involved with conducting a risk assessment with the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems.
During an interview on 03/19/25 at 12:15 P.M., the Maintenance Director said the following:
-The only thing he does with the water management program was check water temperatures weekly;
-He had no facility map or tracing that he does;
-There was no water management team, he was the only one that did anything with it.
-He had never been involved with conducting a risk assessment.
During an interview on 03/20/25 at 4:40 P.M., the DON said the following:
-She would expect the water management program to be followed per policy;
-She was not a part of the water management team;
-She had not been involved with conducting a risk assessment with the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems.
-She was not aware there were things the policy directed the DON to do regarding Legionella.
During an interview of 03/20/25 at 5:05 P.M., the Administrator said she would expect the water management program to be followed per policy.
Dec 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to report allegations of misappropriation of property as required for one resident (Resident #7) in a review of seven sampled residents. The f...
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Based on interview and record review, the facility failed to report allegations of misappropriation of property as required for one resident (Resident #7) in a review of seven sampled residents. The facility census was 60.
Review of the facility's policy titled, Abuse Neglect and Exploitation, undated, showed the following:
-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;
-Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent;
-Reporting of all alleged violations to the Administrator, state agency adult protective services and to all required agencies (law enforcement when applicable) within specified time frames;
-Not later than 24 hours if the events of the allegation do not involve abuse and not result in serious bodily injury.
1. Review of Resident #7's inventory list dated 6/17/24 showed the following:
-A green purse;
-A cell phone and charger.
Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 6/24/24, showed the resident was cognitively intact.
Review of the resident's September 2024 Amazon credit card statement (provided by the resident's Power of Attorney to the state agency) showed the following:
-On 8/20/24, a purchase for $14.99;
-On 8/20/24, a purchase for $26.34;
-On 8/20/24 a purchase for $34.99;
-On 8/20/24 a purchase for $56.99;
-On 8/20/24 a purchase for $58.99.
During an interview on 12/17/24 at 11:50 A.M. the resident's family member and power of attorney (POA) said the following:
-On 8/17/24 when visiting the resident, he/she noticed the resident's iPhone was missing. The family member reported the missing phone to the Director of Nursing (DON);
-On 8/21/24 when visiting the resident, the family member noticed the resident's purse was also missing. The purse contained the resident's bank card, credit card and an Amazon credit card;
-The family member checked to see if any purchases had been made on the resident's cards. There were five charges made on the resident's Amazon credit card on 8/20/24 totaling almost three hundred dollars. The resident did not make the purchases charged to the resident's card;
-The resident did not have access to his her/phone to make any purchases on his/her Amazon account at the time the purchases were made. The resident was also very weak and depressed during this time frame and had no interest in day to day activities;
-He/She canceled all the resident's cards and reported the missing purse along with the charges that were made on the resident's Amazon card to the charge nurse and the DON.
During an interview on 12/17/24 at 10:35 A.M. Certified Nurse Assistant (CNA) A said the following:
-The resident had an iPhone when he/she was at the facility. The resident attached it to a lanyard and wore it around his/her neck;
-The resident also had a blue/teal colored wallet he/she kept in his/her room;
-He/She heard the items were missing from other staff at the facility but couldn't recall when the information was reported to him/her;
-He/She worked routinely on the resident's hall.
During an interview on 12/17/24 at 2:45 P.M. CNA B said the following:
-The resident's iPhone and blue wallet came up missing when he/she was at the facility. CNA B got a message through the facility communication app directing staff to be on the look out for the items missing;
-The resident's family member asked everyone about the missing items;
-He/She worked routinely on the resident's hall.
During an interview on 12/17/24 at 2:35 P.M. the Social Service Director (SSD) said the following:
-He/She was responsible for handling the facility's grievances;
-The missing items should have been reported to the state agency and the police, as the items were costly items.
During an interview on 12/17/24 the DON said she would expect the facility to follow the policy regarding misappropriation and the reporting time frames.
During an interview on 12/17/24 at 2:30 P.M. the facility's corporate nurse said the following:
-She would expect staff to follow the facility policy regarding misappropriation;
-The facility should have reported the resident's missing iPhone, purse and credit cards to the state agency.
MO245720
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to thoroughly investigate allegations of misappropriation made by one resident (Resident #7) in a review of seven sampled residents. The facil...
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Based on interview and record review, the facility failed to thoroughly investigate allegations of misappropriation made by one resident (Resident #7) in a review of seven sampled residents. The facility census was 60.
Review of the facility's policy titled, Abuse Neglect and Exploitation, undated, showed the following:
-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;
-Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, us of a resident's belongings or money without the resident's consent;
-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, witnesses and others who might have knowledge of the allegations;
-Providing complete and thorough documentation of the investigation;
-The Administrator will report the results of the investigation when final within five working days of the incident, as required by state agencies.
1. Review of Resident #7's inventory list, dated 6/17/24, showed the following:
-A green purse;
-A cell phone and charger.
Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 6/24/24 showed the resident was cognitively intact.
Review of a folder the Director of Nurses (DON) identified as the investigation information regarding the resident's missing items from August 2024, showed the following:
-A small hand written note, which included the resident's name with the date 8/17/24, indicating the last day phone was active, and a date of 8/20/24, indicating the date Amazon charges were made;
-A list of staff that worked on 8/20/24;
-The file did not include a resident statement, employee statements or any other documentation regarding the investigation.
Review of the resident's September 2024 Amazon credit card statement (provided by the resident's POA to the state agency) showed the following:
-On 8/20/24, a purchase for $14.99;
-On 8/20/24, a purchase for $26.34;
-On 8/20/24 a purchase for $34.99;
-On 8/20/24 a purchase for $56.99;
-On 8/20/24 a purchase for $58.99.
During an interview on 12/17/24 at 11:50 A.M. the resident's family member and power of attorney (POA) said the following:
-On 8/17/24 when he/she visited the resident at the facility, he/she noticed the resident's iPhone was missing. The family member reported the missing phone to the previous DON;
-On 8/21/24 when he/she visited the resident at the facility, the family member noticed the resident's purse was also missing. The purse contained the resident's bank card, credit card and an Amazon credit card;
-The family member checked to see if any purchases had been made on the resident's cards. There were five charges made on the resident's Amazon credit card on 8/20/24 totaling almost three hundred dollars. The resident didn't make the purchases charged to the resident's card;
-The resident did not have access to his her/phone to make any purchases on his/her Amazon account at the time the purchases were made. The resident was also very weak and depressed during this time frame and had no interest in day to day activities;
-The family member canceled all the resident's cards and reported the missing purse along with the charges that were made on the resident's Amazon card to the charge nurse and the DON;
-The facility did not share any outcome of an investigation and was not sure if anything was ever done to look into the missing items.
During an interview on 12/17/24 at 2:35 P.M. the Social Service Director (SSD) said the following:
-He/She was responsible for handling the facility's grievances;
-He/She did not receive any information or a grievance on a missing iPhone or purse and didn't complete an investigation regarding the resident's missing iPhone or purse;
-He/She heard the previous DON handled the investigation regarding missing items involving the resident;
-A thorough investigation should have been completed.
During an interview on 12/17/24 the DON said the following:
-She had been in his/her position as the DON for approximately a week;
-She would expect the facility to follow the policy regarding misappropriation and complete a thorough investigation.
During an interview on 12/17/24 at 2:30 P.M. the facility's corporate nurse said the following:
-She would expect staff to follow the facility policy regarding misappropriation and complete a thorough investigation into any missing items reported;
-She would expect staff and residents be interviewed and documentation of the investigation;
-The SSD was the facility grievance officer and should have documented the investigation, but the SSD thought the previous DON completed the investigation.
MO245720
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 staff provided four residents (Resident #1, #2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided four residents (Resident #1, #2, #3, and #7), of seven sampled residents, that were unable to complete their own activities of daily living, the necessary care and services to maintain good personal hygiene and staff failed to assist and provide nail care. The facility census was 60.
Review of the facility's policy titled, Nail Care, dated 2024, showed the following:
-The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health;
-Routine cleaning and inspection of the nails will be provided during activities of daily living (ADL) care on an ongoing basis;
-Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on 3-11 shift). Nail care will be provided between scheduled occasions as the need arises;
-The resident's care plan will address the frequency of nail care to be provided, the type of nail care provided and the staff member responsible for the nail care;
-Nails should be kept smooth to avoid injury.
1. Review of the Resident#1's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 9/10/24, showed the following:
-The resident was cognitively intact;
-The resident required partial to moderate assistance with personal hygiene and bathing;
-Received hospice care.
Review of the resident's Care Plan, dated 10/10/14, showed the following:
-Required partial to moderate assistant with bathing and personal hygiene; Hospice aide will provide shower, check nail length, have nurse trim on bath day;
-The resident's diagnoses included malignant neoplasm (cancerous tumor) of prostate, secondary neoplasm of bone, and palliative care (comfort care).
Observation on 12/17/24 at 8:45 A.M. showed the resident's fingernails were uneven with some fingernails over one inch long in length, with brown debris under all of the nails.
During an interview on 12/17/24 at 12:15 P.M. the resident said the following:
-His/Her nails were dirty and too long. He/She didn't have any nail clippers to trim his/her fingernails or he/she would;
-The staff were too busy to take care of his/her fingernails.
2. Review of Resident #2's annual MDS, dated [DATE], showed the following:
-The resident was rarely or never understood;
-Long and short-term memory were ok;
-Range of motion impairment to both upper and lower extremities;
-The resident was dependent on staff for activities of daily living (ADLs);
-Received hospice care;
-Diagnoses included Huntington's disease (a rare, inherited, brain disorder that affects a person's movement, thinking and mental health).
Review of the resident's Care Plan, dated 10/10/24, showed the following:
-The resident needed assistance with ADLs due to decreased strength and balance related to Huntington's disease;
-The resident needed assistance of one to two staff members for bathing;
-Required assistance of two staff members with dressing;
-Required assistance of one staff member with eating;
-The resident received showers from the hospice provider;
-Please keep fingernails trimmed short so the resident wouldn't accidentally scratch himself/herself.
Observation on 12/17/24 at 12:30 P.M. showed the resident's finger nails were uneven with some of the finger nails approximately one inch long in length.
During an interview on 12/19/24 at 1:40 P.M. the resident's family member said the following:
-The resident would normally keep his/her fingernails trimmed much shorter than what they were;
-When he/she visited the resident, which was usually in the evening before the resident received supper, the resident's clothes were often dirty with dried food on them from the noon meal.
3. Review of Resident #3's annual MDS, dated [DATE], showed the following:
-The resident was cognitively impaired;
-Required supervision or touching assistance from staff with meals;
-Substantial/Maximal assistance with upper body dressing;
-Dependent on staff for personal hygiene;
-Received hospice care;
-Diagnoses included dementia.
Review of the resident's Care Plan, revised 10/10/24, showed the following:
-Substantial/Maximal assistance with upper body dressing;
-Required supervision or touching assistance from staff with meals, staff provides verbal cues and or touching/steadying and/or contact guard assistance as activity completed;
-Adjust provision of ADLs to compensate for resident's changing ability, the resident had a terminal disease related to dementia;
-Staff will need to anticipate the resident's wants/needs as much as possible as the resident was unable to express needs and wants.
Observation on 12/17/24 at approximately 12:30 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident's face had dried white colored debris on his/her left check and down the front of the resident's shirt.
Observation on 12/17/24 at approximately 3:30 P.M., showed the resident remained in his/her wheelchair with dried white colored debris on his/her left check and down the front of his/her shirt.
4. Review of Resident #7's significant change in status, MDS dated [DATE], showed the following:
-Cognitively intact;
-Range of motion impairment in both upper and lower extremities;
-The resident was dependent on staff to complete all ADLs.
Review of the resident's Care Plan, dated 11/13/24, showed the following:
-The resident had multiple sclerosis (MS, nerve damage that disrupts communication between the brain and the body) with paraplegia (loss of muscle function in the lower half of the body, including the legs, feet and toes) and needed assistance with ADLs, the amount of assistance may vary;
-Required assistance of one staff member for personal care and bathing;
-Encourage the resident to participate in activities he/she enjoyed, like getting his/her nails done.
During an interview on 12/17/24 at 11:45 A.M. the resident's family member said the following:
-The family member was shocked by the resident's appearance when he/she went to visit. The resident was filthy, with dry crusted skin on his/her face and body, as though the resident had not bathed for a long period. The resident's fingernails were so long they were digging into the resident's palms;
-The resident had an odor of urine and body odor. The resident was always meticulous with his/her appearance and would have never wanted looked like that.
5. During an interview on 12/17/24 at 9:45 A.M. Certified Nurse Assistant (CNA) E said he/she thought the activities staff was responsible for resident's nail care.
During an interview on 12/17/24 at 12:45 P.M. CNA B said the following:
-Nail care was not a CNA task, he/she thought the shower aide was responsible for residents' nail care;
-Resident #7 refused his/her shower a lot, and his/her fingernails were long. Staff probably missed cleaning and trimming Resident #7's fingernails.
During an interview on 12/17/24 at 1:15 P.M. the Director of Nursing (DON) said the following:
-The CNAs were responsible for nail care. If a resident was on Hospice, the hospice CNA should trim the resident's nails on shower days or let facility staff know if the resident's nails needed trimmed;
-She would expect each resident's nails be trimmed and cleaned routinely and as needed;
-She would expect the residents be neat and clean, including clean clothing;
-She would expect the residents to have routine showers at least two times a week.
During an interview on 12/17/24 at 2:30 P.M. the facility's corporate nurse said the following:
-Nail care was not a task that was assigned to the CNAs in the electronic medical record ( EMR). The facility needed to add that task to the EMR to assure it was completed;
-She would expect the resident's be neat and clean, including clothing.
MO245720
Jun 2023
4 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and a closed record review for six residents, the facility failed to notify one resident's physician (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and a closed record review for six residents, the facility failed to notify one resident's physician (Resident #55) timely when the resident had continued diarrhea after the implementation of medication to stop diarrhea, incontinence and vomiting with stomach pain. In addition, the facility failed to notify the resident's physician timely of abnormal laboratory results, faxing rather than calling the physician. The physician did not see the laboratory results for review for two days (faxed on [DATE], a weekend, and not reviewed until [DATE]). The resident had repeatedly requested to be sent to the hospital for treatment over a period of twelve days. The resident's physician was not aware of these repeated requests. On [DATE], the resident was hospitalized with abnormal laboratory results and a change in condition which included incontinence, weakness, nausea and vomiting and confusion. The resident was transferred from a local hospital to a regional hospital and admitted with diagnoses that included dehydration, metabolic acidosis (a condition that occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body), hyperkalemia (electrolyte disorder where there is too much potassium in the blood), hyponatremia (electrolyte disorder where there is a low level of sodium in the blood), hyperphosphatemia (electrolyte disorder where there is an elevated level of phosphate in the blood), likely secondary to dehydration/hypovolemia (a condition in which the liquid portion of the blood is too low, likely caused from vomiting and/or diarrhea). The resident expired while in the hospital on [DATE]. The resident's death certificate showed the cause of death to include hypovolemic shock (an emergency condition in which severe blood or other fluid loss makes the heart unable to pump enough blood to the body). The facility census was 50.
The administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 6:00 P.M. which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification.
Review of the facility's policy, Notification of Changes, dated 1/2023, showed the following:
-The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification;
-Significant change in the resident's physical, mental or psychosocial condition, such as deterioration in health, mental or psychosocial status. This may include life-threatening conditions or clinical complications;
-Circumstances that require a need to alter treatment. This may include new treatment or discontinuation of current treatment due to adverse consequences, acute condition or exacerbation of a chronic condition.
Review of the facility's policy, dated 01/2023, Laboratory Services and Reporting, showed the following:
-The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law;
- Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.
1. Review of Resident #55's face sheet showed the following:
-The resident was admitted to the facility on [DATE];
-The resident was his/her own person.
Review of the resident's facility medical diagnoses page showed diagnoses included acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), chronic kidney disease (long-standing disease of the kidneys leading to kidney failure), diabetes mellitus (too much sugar in the blood), and sleep related leg cramps.
Review of the resident's facility Order Summary Report, undated, showed an order for complete blood count (CBC, a laboratory test that provides information about the cells in a person's blood), a comprehensive metabolic panel (CMP, a laboratory test that measures 14 different substances in the blood and provides important information about the body's chemical balance and metabolism), A1C (a blood test that helps to determine the average blood sugar values over time), lipids (a blood test that checks for the fat content in the bloodstream), once every six months, starting on the 24th for one day for routine labs. Order date [DATE], start date [DATE].
Review of the resident's facility Order Summary Report, undated, showed the following medications ordered on admission to the facility:
-Lasix (furosemide, a diuretic medication that treats fluid retention and swelling caused by heart failure, liver or kidney disease as well as other medical conditions), 40 milligram (mg) tablet, give 1 tablet by mouth in the morning for fluid retention;
-Potassium chloride (an electrolyte to help body function normally by maintaining fluid and blood volume) Extend Release (ER, releases the medication over a period of time), 20 millequivalents (mEq), give 1 tablet by mouth in the morning for Lasix use supplement;
-Tramadol HCL (Tramadol hydrochloride, a mild narcotic pain medication with a substance added to make it dissolve more readily in the stomach and blood stream), oral tablet 50 mg, give 1 tablet by mouth every 4 hours as needed for first line pain;
-Hydrocodone-acetaminophen (a narcotic pain medication for more severe pain) oral tablet 5/325 mg give 1 tablet by mouth every six hours as needed for pain, second line for pain.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, dated [DATE], showed the following:
-Adequate hearing;
-Clear speech;
-Made self-understood;
-Cognitively intact;
-No behaviors or rejection of cares;
-Required extensive assistance by two staff for bed mobility, transfers, locomotion off the unit, dressing and toileting;
-Required limited assistance by one staff for walking in the room or corridor, locomotion on the unit, and personal hygiene;
-Required no assistance and was independent for eating;
-Had an indwelling urinary catheter (a flexible tube that is placed into the bladder and drains urine from the bladder into a bag by gravity);
-Frequently incontinent of his/her bowel (two or more episodes of bowel incontinence, but at least one continent bowel movement);
-On scheduled and as-needed pain medication in the previous five days;
-Had frequent pain;
-Had a fall in the last month prior to his/her admission to the facility;
-Had no swallowing issues.
Review of the resident's care plan, dated [DATE], showed the following:
-The resident had a potential nutritional problem;
-The resident will not lose 5% of his/her body weight through the review date;
-Alert the dietician if the resident's consumption is poor for more than 48 hours, explain and reinforce to the resident the importance of maintaining the diet order, encourage the resident to comply;
-Provide and serve the resident his/her diet as ordered. Assess the resident's intake and record meals. Registered Dietician (RD) to evaluate and make diet change recommendations;
-The resident is incontinent of his/her bowels at times, risk for urinary tract infection (UTI, urinary catheter) and constipation;
-Signs and symptoms of UTI and issues with his/her bowels will be recognized and addressed promptly through the next review;
-It is important for the resident's nurse to keep track of his/her bowel movements. Please observe for bowel records to ensure the resident has a bowel movement at least every three days. Notify the resident's physician of any signs of a problem (sluggish bowel sounds, abdominal pain), or if the resident does not have a bowel movement in three days and the medications already ordered have not helped;
-The resident is at risk for pain due to a recent sacral fracture and burn to the right hand;
-Signs and symptoms of pain will be recognized and addressed promptly through the next review date;
-Facility staff will need to monitor the resident for pain as he/she may not always tell them;
-Administer pain medication as ordered, monitor the resident for the effectiveness of the pain medication and notify the physician if the resident is unable to be kept comfortable.
Review of the resident's comprehensive metabolic panel (CMP), dated [DATE] showed the following:
-Sodium (electrolyte to help body function normally by maintaining fluid and blood volume): 138 millimoles per liter (mmol/L), reference range 137-145 mmol/L;
-Potassium (electrolyte to help body function normally by maintaining fluid and blood volume): 4.8 mmol/L, reference range 3.3-4.9 mmol/L;
-Creatinine: (most sensitive indicator/measurement of kidney function) 1.85 milligrams per deciliter (mg/dL), reference range 0.06-1.10 mg/dL;
-No documentation the physician was notified of the resident's CMP results.
Review of the resident's Medication Administration Record (MAR) for the month of March, 2023, showed staff documented administering the following:
-On [DATE] and daily through [DATE], Tramadol hydrochloride 50 mg one tablet by mouth every four hours as needed for pain; the medication was discontinued on [DATE];
-On [DATE], [DATE], [DATE] and [DATE], hydrocodone/acetaminophen 5/325 mg one tablet by mouth every six hours as needed for pain; the medication was discontinued on [DATE];
-On [DATE] and through [DATE], potassium chloride ER 20 meq one tablet by mouth daily in the morning.
Review of the resident's nursing progress notes on [DATE] at 12:16 A.M. showed the following:
-The resident requested his/her as needed Tylenol Extend Release (ER) and rated his/her pain at an 8 (pain score of 0 to 10, with 10 being the highest pain score indicating the worst pain); he/she is in so much pain, that he/she needs two Tylenol. Staff had been giving him/her two tabs, educated that the order was for one tab every six hours as needed. The resident requested clarification from the physician.
Review of the resident's medical record showed no documentation staff notified the resident's physician of the resident's request to clarify pain medication.
Review of the resident's nursing progress notes showed staff documented on [DATE] at 10:08 A.M., the resident had a loose stool this morning, new order received for Imodium (a medication used to treat diarrhea) every six hours.
Review of the resident's order management note, dated [DATE] at 10:08 A.M., showed staff documented the new order for Imodium A-D (anti-diarrheal) capsule, 2 mg, give two capsules by mouth every six hours as needed for first loose stool, then one capsule after each loose stool, do not exceed 24 mg in 24 hours.
Review of the resident's MAR for the month of March, 2023, showed staff documented on [DATE] at 11:30 A.M. and 5:17 P.M., administration of Imodium A-D Capsule 2 mg., give two capsules by mouth every six hours as needed, for first loose stool two capsules, then one after each loose stool, do not exceed 24 mg in 24 hours.
Review of the resident's nursing progress notes showed staff documented the following:
-On [DATE] at 10:55 A.M., the resident said he/she thinks he/she is dehydrated because he/she has diarrhea. Resident given Imodium this morning. Resident said he/she hasn't had another loose stool this morning after Imodium given. He/She had leg cramps last night and the night prior and could not sleep. Resident encouraged to drink fluids. Physician notified (via fax);
-On [DATE] at 4:22 P.M., physician acknowledged fax received regarding loose stools and leg cramps, orders to continue Imodium and to push oral (P.O.) fluids.
Review of the resident's MAR for the month of March, 2023, showed staff documented administering the following:
-On [DATE] at 8:08 A.M. and [DATE] at 12:02 A.M. and 8:13 A.M., Imodium-AD 2 mg, two capsules by mouth (indicating the resident continued to have diarrhea);
-On [DATE] and [DATE], potassium chloride ER 20 meq one tablet by mouth daily.
Review of the resident's nursing progress notes showed staff documented the following:
-On [DATE] at 10:16 P.M., called to resident's room. Resident demanded he/she be sent to the emergency room (ER) for malnutrition and dehydration due to loose stools. Resident drank Gatorade (electrolyte liquid) today and was drinking water when staff entered the room. Resident said everything he/she has eaten the past two days had gone right through him/her and he/she knows he/she is malnourished. Explained staff aware he/she was drinking fluids and he/she was not malnourished. The resident said no one was taking him/her seriously and he/she wanted to go somewhere else to address his/her pain and he/she couldn't get relief. He/She then requested Tylenol (pain relief medication) and it was given. There was no documentation to show staff assessed the resident for dehydration, (skin turgor, mucous membranes, temperature or urine output - resident had a urinary catheter), no documentation of amount of fluids consumed and no documentation to support that the resident's physician was notified of the resident's request to go to the ER, or of his/her concerns at that time;
-On [DATE] at 3:51 A.M., the resident continued to ask if he/she could go to the hospital for his/her leg cramps, and he/she wanted magnesium (supplement) and something for pain other than Tylenol. The resident still believed he/she was malnourished;
-No evidence of documentation of an assessment of the resident's hydration status (skin color, temperature or oral mucosa), and no documentation of any amount of fluid intake.
Review of a facility document - fax to the resident's physician, dated [DATE] at 4:00 A.M., showed the unnamed staff documented the following:
-The resident has been awake all night, wanting to go to the emergency room (ER) for leg cramps and to get pain pills. May the facility try some magnesium? (a mineral that is important for many processes in the body, including muscle and nerve function, blood sugar levels, and blood pressure). The resident takes Lasix 40 mg and potassium 20 mEq daily;
-The physician responded (no date/time): Magnesium 400 mg daily and Baclofen (a medication used to relax muscles) 10 mg two times daily as needed;
-Illegible staff signature documented Noted on [DATE], no time indicated.
Review of the resident's nursing progress notes on [DATE] at 6:23 P.M. showed staff documented the resident's catheter removed this day with assistance of night shift nurse. No odor, redness to skin or signs or symptoms of infection. Resident denies pain or burning with urination. Resident is able to make needs known and was compliant with cares.
Review of the resident's MAR for the month of March, 2023, showed the staff documented administering the following:
-On [DATE] at 8:25 A.M., Imodium-AD 2 mg, two capsules by mouth (indicating the resident continued to have diarrhea);
-On [DATE], potassium chloride ER 20 meq one tablet by mouth daily.
Review of the resident's Order Summary Report, undated, showed the following:
-[DATE], Baclofen 10 mg by mouth every 12 hours as needed for leg spasms;
-[DATE], magnesium oral tablet, give 400 mg. by mouth in the morning for leg cramps.
Review of the resident's nursing progress notes showed staff documented the following:
-On [DATE] at 8:57 A.M., resident started on magnesium daily related to cramps. No signs or symptoms of adverse reactions. Resident continues to have complaints of muscle cramps, utilizing as needed (PRN) medication;
-On [DATE] at 10:42 P.M., the resident is upset and thinks he/she needs to go to the hospital, he/she is in so much pain. None of the medications he/she is taking are working. The resident thinks he/she has an infection and needs an antibiotic. The resident has not been able to sleep for four nights and did not sleep today. This is all affecting his/her heart and he/she will have another heart attack. This nurse did educate the resident he/she had only had magnesium two times and one dose of Baclofen and that it does not work right away. Explained that labs were done on [DATE] and his/her labs were within normal limits. Did take his/her vitals and within normal limits: Blood pressure 119/60 (normal is less than 120/80), heart rate 50 (normal is 60-100), respirations 18 (normal is 12-20), temperature 98.7 degrees Fahrenheit (F) (normal is 98.6), oxygen (O2) saturation 95 percent (%) on room air (normal is 95% or higher). Did explain that antibiotics not needed as he/she does not have a fever. The resident said again the pain medication was not working. The resident did not know why the physician took away the Tramadol and Norco, they were the only thing that worked. The resident said he/she was thinking of calling his/her family member to take him/her to the hospital because the facility was not doing anything for him/her. Again tried to explain that he/she was on magnesium daily, Baclofen as needed every 12 hours just taken at 1:30 P.M. and Tylenol as needed every six hours (given at 5:00 P.M.) and he/she can have this again at 11:00 P.M. The resident said okay then. There was no documentation staff notified the resident's physician of the resident's concerns.
Review of the resident's MAR for the month of April, 2023 showed staff documented administering the following:
-On [DATE], potassium chloride ER 20 meq one tablet by mouth daily in the morning;
-On [DATE], magnesium 400 mg by mouth daily in the morning;
-On [DATE] at 1:28 P.M., Baclofen 10 mg by mouth.
Review of the resident's nursing progress notes showed staff documented the following:
-[DATE] at 2:16 A.M., resident complained to this nurse that the Tylenol Extend Relief (pain medication) did not work. The resident laid in bed with legs crossed and said he/she needed arrangements made to go to the hospital, he/she knew what was going on, he/she has broken his/her tailbone again. When this nurse asked him/her how, he/she said by rolling around in this hard bed. The resident has not gotten any sleep;
-There was no documentation to support that the resident's physician was notified of the resident's uncontrolled pain, concerns or request to go to the hospital.
Review of the resident's nursing progress note, dated [DATE] at 5:33 A.M., showed staff documented the resident was found on the floor in the bathroom, staff assist times two to stand and placed him/her on the toilet. The resident walked back to his/her bed with a slow steady gait. The resident reported his/her legs were hurting so bad, but will not take Tylenol Extended Release (ER) due to it not helping.
Review of the resident's MAR for the month of April, 2023 showed staff documented administering the following:
-On [DATE] and [DATE], potassium chloride ER 20 meq one tablet by mouth daily;
-On [DATE] and [DATE] magnesium 400 mg by mouth daily in the morning;
-On [DATE] at 2:02 A.M. and 2:54 P.M., [DATE] at 3:39 A.M. and 3:53 P.M., Baclofen 10 mg by mouth as needed for leg pain;
-On [DATE] at 10:16 P.M., [DATE] at 8:39 A.M. and 8:30 P.M., Imodium-AD 2 mg, two capsules by mouth (indicating the resident continued to have diarrhea).
Review of the resident's nursing progress notes, dated [DATE] at 10:41 P.M., showed staff documented the following:
-On [DATE] at 5:10 A.M. (late entry), was walking another resident back to room, the resident's roommate was in his/her doorway talking to staff when (the writer) asked him/her what he/she needed. The resident' roommate said the resident was on the floor. Observed the resident on his/her left side with feet towards the toilet and head toward the door with walker in the doorway. He/She said he/she was trying to go to the bathroom, but lost his/her balance and fell on the floor. This nurse got (the) certified nurse assistant (CNA), sat him/her up, checked his/her left side, no redness noted, applied gait belt and assisted him/her to stand, checked his/her left hip and leg, no redness or bruising noted. The resident said he/she needed to use the bathroom, assisted to bathroom and back to bed. Notified the resident's physician of incident, the Director of Nurses (DON) was also notified. Resident is self-responsible.
Review of the resident's nursing progress notes, dated [DATE] at 10:56 P.M., showed staff documented the following:
-The resident is having behaviors and refusing to help with cares. He/She turned on his/her call light and told the CNA that he/she (soiled) him/herself. When the CNA went to remove the resident's brief, he/she had taken it off and thrown it on the floor and the brief was still clean. He/She was found with bowel movement from mid back to mid-thigh. The CNA had to do a complete bed change with linen and the resident refused to help with turning or standing to assist with getting him/herself cleaned up. Got a second CNA to assist. Resident told CNA that he/she cannot help himself/herself.
Review of the resident's nursing progress notes, dated [DATE] at 10:58 P.M., showed the staff documented the following:
-Post fall evaluation: date/time of fall: [DATE] 5:11 A.M., fall was not witnessed;
-Fall occurred in bathroom;
-Resident was attempting to self-toilet at time of the fall, reason for the fall was evident;
-Reason for fall: independent with toileting, resident said he/she lost his/her balance and fell to the floor; (resident was extensive assistance by 2 staff for toileting per MDS)
-No injury occurred as a result to the fall;
-The resident's physician was notified on [DATE] of fall without injury;
-Skin warm, dry, skin color within normal limits (WNL) and turgor (the elasticity of the skin) is normal;
-No decrease in fluid intake;
-No change in mental status;
-No change in behaviors.
Review of the resident's MAR for the month of April, 2023 showed the staff documented administering the following:
-On [DATE], potassium chloride ER 20 meq one tablet by mouth daily;
-On [DATE], magnesium 400 mg by mouth daily in the morning;
-On [DATE] at 8:32 A.M., Baclofen 10 mg by mouth as needed for leg pain;
-On [DATE] at 8:53 A.M. and 8:34 P.M., Imodium-AD 2 mg, two capsules by mouth (indicating the resident continued to have diarrhea).
Review of a document faxed to the resident's physician, dated [DATE], no time indicated, showed the unnamed staff documented the following:
-The resident is requiring more assistance, yellow, loose stool. Blood pressure 107/44, pulse 46, temperature 97.8 degrees F, O2 saturation 95%, respiratory rate 16. Vitals taken while napping, complains of restless leg pain daily;
-The physician responded to get urinalysis (a urine sample to check for an infection), stool samples for clostridium difficile (a bacterial infection that causes inflammation in the colon), CBC and a CMP, dated [DATE], no time indicated;
-Illegible staff signature indicated Noted on [DATE], no time indicated;
Review of the resident's MAR for the month of April, 2023 showed staff documented administering the following:
-On [DATE] and [DATE], potassium chloride ER 20 meq one tablet by mouth;
-On [DATE] and [DATE], magnesium 400 mg by mouth;
-On [DATE] at 8:05 A.M. and [DATE] at 8:21 A.M., Baclofen 10 mg by mouth;
-[DATE] at 8:22 A.M., Imodium-AD 2 mg, two capsules by mouth (indicating the resident continued to have diarrhea).
Review of the resident's General Nurse Practitioner (NP) progress note dated [DATE], untimed, showed the NP documented the following:
-The resident reported bright yellow diarrhea for approximately two weeks. He/She denies abdominal pain. He/She has labs pending for this;
-The facility staff said he/she complains of bilateral leg cramps and generalized weakness and is requesting pain medication;
-The facility staff said his/her heart rate and blood pressure had been abnormally low recently;
-The resident's assessments included diarrhea, chronic pain, diabetes mellitus and fluid retention;
-Plan included results of labs and continue to monitor the resident. If the resident's condition worsened, the facility staff will notify the provider(s) and the resident would be sent out. The resident will continue the following medications as ordered: acetaminophen/hydrocodone 325/5 mg one tab every six hours as needed for pain, Tramadol 50 mg one tab every four hours as needed for pain, (these medication had been discontinued), diclofenac gel (a gel used on the skin to treat arthritis pain) four times a day as needed, metformin (a medication that helps to regulate the blood sugar) 1000 mg two times a day, and furosemide (Lasix) 40 mg one tab daily. Follow-up with the resident would be in two to four weeks or sooner if needed.
Review of the resident's nursing progress notes, dated [DATE] at 10:54 A.M., showed staff documented the following:
-The resident's NP made rounds this day;
-No new orders were received pending the urinalysis and lab results taken yesterday;
-NP advised if resident needs to go to the hospital, okay to send if blood pressure is hypotensive;
-The resident is alert, oriented to person, place and time;
-No documented evidence of the resident's hydration status (skin color, turgor, oral mucosa or urine output);
-No documentation to show the resident had fluid retention or edema.
Review of the resident's nursing progress notes, dated [DATE] at 12:45 P.M., showed staff documented they were called to the resident's room and when this nurse entered the room, the resident was sitting on the floor with legs crossed and back against the bed. No signs or symptoms of distress or injuries. Assistant Director of Nurses (ADON) and another registered nurse (RN) was in the room at bedside with the CNA. Resident was anxious and was concerned with an item he/she was looking for. Mini activities of daily living (ADL), skin, pain and vital assessment conducted. Resident was assisted by two staff to his/her feet and then sat on the bed. No further complaints. Lunch provided and resident was dressed for physician's appointment. Resident is currently sitting in bed eating lunch at bedside table.
Review of the resident's nursing progress notes, dated [DATE] at 1:38 P.M., showed staff documented UA and blood work results receivd. Sent to doctor's office.
Review of the resident's laboratory results obtained on [DATE] showed the following:
-Sodium: 133, (reference range 137-145 mmol/L);
-Potassium: 4.5, (reference range 3.3-4.9 mmol/L);
-Creatinine: 2.20, (reference range 0.06-1.10 mg/dL);
-Clostridioides difficile toxin: negative, (normal is negative).
Review of the resident's (Microbiology) laboratory results, Urine Culture Preliminary, collected on [DATE] at 1:49 P.M. showed the following:
-Urine sample: slightly cloudy (normal finding: clear), positive protein (normal finding, negative), positive nitrite (normal finding, negative), moderate leukocytes (normal finding, negative);
-Urine preliminary culture: greater than 100,000 colony forming units per milliliter (CFU/ml, a measurement of bacteria in the urine, normal finding is negative) of a gram negative bacilli (a type of bacteria that can cause a urinary tract infection, normal finding is negative for bacteria.)
Review of the resident's nursing progress notes, dated [DATE] at 4:02 P.M., showed staff documented the following:
-Resident returned with transportation with new orders from the cardiologist for labs including a CMP, thyroid stimulating hormone (TSH, a test that measures thyroid function) and follow-up with the nurse practitioner (NP). (No specific date indicated for when to obtain labs)
Review of the resident's (Microbiology) laboratory results, Urine Culture Final, collected on [DATE] at 1:49 P.M. and resulted on [DATE] at 1:28 P.M. showed the following:
-Urine final culture: mixed genital flora (a term that is used to indicate the presence of contamination in the urine by skin, this can mean there is no bacterial infection) isolated (seen under the microscope). These superficial bacteria are not indicative of a urinary tract infection.
Review of the resident's MAR for the month of April, 2023 showed the staff documented administering the following:
-On [DATE], potassium chloride ER 20 meq one tablet by mouth;
-On [DATE], magnesium 400 mg by mouth daily;
-On [DATE] at 8:25 A.M., Baclofen 10 mg by mouth;
-On [DATE] at 10:44 P.M., Imodium-AD 2 mg, two capsules by mouth (indicating the resident continued to have diarrhea).
Review of the resident's nursing progress notes, dated [DATE] at 9:23 A.M., showed staff documented they called the hospital for lab results, UA results and stool sample results. They (the hospital) will fax.
Review of the resident's CMP laboratory results on [DATE] (untimed) showed the following:
-Sodium: 131 (a decrease from 133 noted on his/her [DATE] laboratory result), (reference range 137-145 mmol/L);
-Potassium: 5.4 (an increase from 4.5 noted on his/her [DATE] laboratory result), (reference range 3.3-4.9 mmol/L);
-Creatinine: 3.40 (an increase from 2.2 noted on his/her [DATE] laboratory result and an increase from his/her baseline creatinine of 1.85 on [DATE]), (reference range 0.06-1.10 mg/dL).
Review of a facility document faxed to the resident's physician, dated [DATE] at 10:10 A.M., from Licensed Practical Nurse (LPN) B, showed the resident's labs were drawn [DATE], need to be reviewed.
Review of the resident's nursing progress notes, dated [DATE] at 10:18 A.M., showed staff documented, {Laboratory Note} Faxed copy of results to (physician) for review.
Review of the resident's MAR for the month of April, 2023 showed the staff documented administering the following
-On [DATE] and [DATE], potassium chloride ER 20 meq one tablet by mouth daily;
-On [DATE] and [DATE], Macrobid 100 mg by mouth given twice each day during block times of 8:00 A.M. to 1:00 P.M. and evening to 4:00 P.M.;
-On [DATE] and [DATE], magnesium 400 mg by mouth daily;
-On [DATE] and [DATE], twice each day during block times of 8:00 A.M. to 1:00 P.M. and evening to 4:00 P.M., Macrobid (an antibiotic commonly used for an infection of the urinary tract system), 100 mg by mouth two times a day for urinary tract infection (UTI), start date of [DATE].
Review of the resident's nursing progress notes, dated [DATE] at 6:00 P.M. showed the staff documented the following:
-The resident was incontinent (did not indicate if bowel, bladder or both) and had vomit in his/her bed and on the floor; he/she used the call light all day after the fact;
-The staff encouraged fluids all shift (this was the first documented entry related to pushing fluids for the resident since the physician ordered the pushing of fluids on [DATE]);
-The resident was given a wash basin to throw up in and encouraged to use his/her call light if he/she needed help to the bathroom;
-The resident had another incontinent episode (did not indicate if bowel, bladder or both) and vomited in his/her supper container.
Review of the resident's medical record showed no documentation staff notified the resident's physician or NP of the resident's change in condition including incontinence and vomiting on [DATE].
Review of the resident's nursing progress notes, dated [DATE] at 6:32 A.M., showed staff documented the following:
-The resident was requesting someone help him/her vomit, he/she said his/her stomach hurt and he/she could not vomit on his/her own;
-Offered the resident Zofran (a medication used to treat nausea) but he/she refused the offer.
Review of the resident's medical record show no documentation staff notified the resident's physician or NP of the resident's complaints of his/her stomach hurting and his/her inability to vomit.
Review of the resident's MAR for the month of April, 2023 showed the staff documented administering the following:
-On [DATE], potassium
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the environment in the facility to ensure the interior and e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the environment in the facility to ensure the interior and exterior of the facility were in good repair. The facility census was 50.
1. Observation on 5/16/23, at 8:04 A.M. and 8:52 A.M., showed the following:
-One of three lights, located in the dishwashing area of the kitchen, was not working;
-One of five lights, located in the food preparation and cooking area of the kitchen, was not working;
-One of six lights, located above the steam table and coffee/tea maker area of the kitchen, was not working;
-Two of the six light covers for the lights, located above the steam table and coffee/tea maker area of the kitchen, were damaged. One cover had two 6 inch cracks and the other cover had a 2 inch by 2 inch hole;
-One of two lights, located in the dry storage room adjacent to the kitchen, had no light cover.
During an interview on 5/16/23, at 4:33 P.M., the Administrator said the following:
-He expected the lights to work and for the light covers to be intact and not damaged;
-He was unaware of the missing light cover in the dry storage room near the kitchen.
2. Observation on 5/17/23, at 2:27 P.M., of the exterior of the building, showed the following:
-Approximately 25 percent of the wooden fascia board, located on the main entrance awning, was rotted and had missing paint;
-Approximately 25 percent of a 15 foot by 6 inch section and a 6 inch by 4 inch section of the white siding, located above the columns holding up the awning at the main entrance, was rotted and had peeling/missing paint.
Observation on 5/17/23, between 2:29 P.M. and 3:45 P.M., during a tour of the interior of the facility, showed the following:
-In the front entryway between the entrance to the east hall and the business offices:
-An 1/8 inch by 12 foot long crack in the ceiling;
-Approximately six areas of the wallpaper, ranging in length from 4 inches to 12 inches, were peeling at the seams and coming away from the wall;
-In the television/resident common area room:
-An 1/8 inch by 5 foot crack in the ceiling;
-A 2 inch by 3 foot area of patched ceiling was unpainted and untextured to match the rest of the ceiling;
-A 1 foot by 2 inch circular area on the ceiling was discolored light brown;
-A 1 inch by 4 foot section of the ceiling was not painted the same color as the rest of the ceiling;
-In the women's bathroom located at the front lobby area:
-An approximate 8 inch hairline crack in the sink basin;
-Approximately 25 percent of the metal 2 foot by 3 inch baseboard heater vent cover was speckled with rust;
-An approximate 6 inch by 6 inch area of vinyl flooring, located under the wall-mounted soap dispenser, was discolored brown;
-In the men's bathroom located at the front lobby area:
-Approximately 25 percent of the metal 2 foot by 3 inch baseboard heater vent cover was speckled with rust;
-A 6 inch by 6 inch area of vinyl flooring, located under the wall-mounted soap dispenser, was discolored brown;
-An approximate 2 inch by 2 inch area of the sink faucet was corroded;
-In the room labeled 'Bath' located on the south side across from the nurses' station in the east hall:
-The base of the toilet was offset approximately 1 inch to the right of its original location;
-The caulk around the base of the toilet, in an approximate 1 inch by 6 inch section, was not smooth and was peeling away on the left side of the toilet;
-A 1 inch by 3 inch piece of black [NAME] material was located underneath the right side of the base of the toilet;
-A 1 inch by 2 foot section of white wall, located on the left side of the room, was scraped and revealed the previous beige-colored paint;
-A 1 inch by 1 inch hole, with a 4 inch by 4 inch section of the area that showed exposed drywall and visible drywall mesh tape, was located on the wall under the wall-mounted soap dispenser;
-In occupied resident room [ROOM NUMBER], an approximate 2 inch by 6 inch area of paint, located on the south wall under the window, was scraped off and showed the area as white on the beige wall;
-In occupied resident room [ROOM NUMBER]:
-The blue vinyl chair (provided by the facility) had a 0.5 inch hole in the vinyl material on the right arm and both wooden legs were very chipped and worn with approximately 75 percent of the finish not present;
-A 3 foot by 4 foot section of the ceiling was without ceiling texture to match the rest of the ceiling, and a 2 foot by 0.25 inch crack was visible in the ceiling drywall. The resident said it would be nice if the ceiling texture was all there;
-The gray and white dresser (provided by the facility) was missing the drawer pulls on the bottom drawers and the bottom drawers were not aligned on the drawer tracks of the frame;
-A 5 inch by 5 inch scraped area, with the previous blue-colored paint showing through, was on the tan wall on the right side of the room;
-In occupied resident room [ROOM NUMBER]:
-The wooden four drawer dresser (provided by the facility) was very worn, had approximately 50 percent of the finish missing, and had scratches and chipped areas throughout the surface of the dresser. The resident said the dresser was there when he/she moved in and it was an eyesore, like it came from a college dorm;
-The left bottom side of the wooden closet door had a 6 inch by 0.5 inch section of veneer missing and a 0.5 inch by 2 inch corner was chipped showing the exposed particle board material;
-In occupied resident room [ROOM NUMBER], a 3 inch by 1/8 inch area of the metal bronze-colored light switch cover, located at the left side entrance to the room, was corroded, raised, and not smooth to the rest of the cover's surface;
-In occupied resident room [ROOM NUMBER]:
-On the white room door, approximately six 1 inch by 0.5 inch areas of peeling paint and an approximate 1 foot by 2 foot section of uneven paint surface, showed the previous blue paint color;
-The brown wood veneer on the closet was chipped in three approximate 1 inch by 2 inch sections and a 0.5 inch by 6 inch section;
-A 2 inch by 3 inch section of the brown wood veneer was missing from the bottom of the closet;
-In the hall located outside of occupied resident room [ROOM NUMBER], a 1 inch by 8 inch area along the ceiling edge above the wall had peeling paint and exposed paper drywall tape;
-In occupied resident room [ROOM NUMBER]:
-The resident in the room sat in the recliner (provided by the facility) and said the recliner was not comfortable. The recliner was light blue in color and showed visible wear throughout the cloth material of the recliner;
-Two pieces of black tape were adhered to the heating, ventilation, and air conditioning (HVAC) wall unit vent cover and the right side HVAC vent cover pivot pin was broken which caused the cover to be loose;
-The back side of the room door had a 1 inch by 3 foot gouge into the white paint;
-In the hall located outside of occupied resident room [ROOM NUMBER], the ceiling was cracked in an approximate 8 foot by 2 inch section and had missing ceiling texture and showed exposed mesh drywall tape;
-In occupied resident room [ROOM NUMBER]:
-The HVAC wall unit vent cover was loose and had two pieces of black tape adhered to the vent cover and HVAC unit;
-A 1 inch by 2 inch raised section of wall, with exposed white drywall showing through the brown paint, was located above the HVAC wall unit;
-The right wooden leg of a chair (provided by the facility) was attached to the chair's frame with two screws and there was an approximate 0.25 inch visible gap between the leg and the frame. The chair was not steady;
-In occupied resident room [ROOM NUMBER], approximately four 0.5 inch by 1 inch areas, located on the left bottom portion of the wooden closet doors, were chipped and showed the exposed particle board material;
-In occupied resident room [ROOM NUMBER], the pink vinyl chair with wooden legs (provided by the facility) had a 1 inch hole in the left vinyl arm material and the legs were very worn with approximately 50 percent of the finish missing;
-Near the nurses' station located on the west hall:
-An approximate 3 inch by 12 foot section and a 3 inch by 10 foot section of the ceiling was cracked and the textured paint was separating from the ceiling surface;
-A 1 foot by 2 inch area of the ceiling was without texture to match the rest of the ceiling texture;
-A 2 inch by 3 inch area of the white ceiling was discolored light brown;
-In the chapel, approximately seven 2 inch by 3 inch areas on the walls were patched white and were unpainted to match the rest of the beige-colored walls;
-In the hall located outside of occupied resident room [ROOM NUMBER], a 2 foot by 3 foot section of the ceiling was patched and had no ceiling texture to match the rest of the textured ceiling;
-In the west hall nurses' station, an approximate 1 foot by 2 inch section of the right side of the medication room's white metal door frame was not painted to match the white paint of the frame and showed the previous blue paint color;
-In the main resident dining room:
-Four approximate 4 inch by 4 inch metal electrical plate covers, located at the peak of the ceiling, were unpatched and unpainted to match the rest of the ceiling;
-An HVAC unit, located in the middle portion of the wall at the end of the dining room under the windows, had two pieces of black tape and tape residue on the HVAC vent cover, the vent cover was coming away from the HVAC unit approximately 0.5 inches, and the trim around the HVAC unit was coming away from the wall that started with a 0.25 inch gap that gradually increased to a 2 inch gap;
-Approximately 20 areas of the brown vinyl floor seam edges (where the individual floor tiles were adhered next to each other to create the floor surface) were chipped and raised, which created an uneven floor surface;
-In the sitting area/small dining area next to the main resident dining room:
-An approximate 8 foot by 0.5 inch section of the ceiling was patched and was not painted or textured to match the rest of the ceiling;
-Approximately five areas of the brown vinyl floor seam edges were raised and were discolored with a black substance that had been applied to the seam edges but that did not create a smooth surface with the floor;
-An approximate 0.5 inch by 4 inch section of the cove base, located between two wooden sets of double doors, was coming away from the wall;
-A red vinyl sofa with wooden legs showed the legs were very scuffed and had approximately 50 percent of the finish missing.
3. During an interview on 5/17/23 at 1:15 P.M., the Administrator said the following:
-The maintenance director was responsible for repairs at the facility;
-The furniture and closet doors in resident rooms were old and were in poor condition;
-The finish was coming off the faucet fixtures which made it difficult to clean them;
-There were cracks and holes in the drywall that needed to be repaired by a drywall specialist;
-There had been plans for a renovation at the facility but he wasn't sure it would occur now that there had been issues identified with the kitchen range hood and fire doors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
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 nursing staff performed acceptable infection c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination when staff failed to protect nebulizer masks while not in use for three residents (Resident #5, Resident #39 and Resident #44), according to the facility policy, and failed to change and document the change of oxygen and nebulizer tubing according to facility policy for four residents (Resident #5, Resident #34, Resident #39 and Resident #44) in a review of 13 sampled residents. The facility census was 50.
Review of the facility's policy, Cleaning of Oxygen Tubing, dated 2022, showed the following:
-Purpose: to prevent the spread of infection;
-Oxygen tubing will be changed every Saturday on night shift;
-The tubing must be labeled with the date and stored in a zip lock bag when not in use.
Review of the facility policy, Cleaning of Nebulizer Tubing, dated 2022, showed the following:
-Purpose: to prevent the spread of infection:
-Nebulizer tubing will be changed every Saturday on Night Shift;
-The tubing must be labeled with the date and stored in a zip lock bag when not in use;
-After each use, the tubing will be rinsed with water and placed on a clean towel to dry. Cover with a clean towel or place in a zip lock bag for storage.
1. Review of Resident #5's Physician Order Summary (POS), dated 03/29/23, showed the following:
-Oxygen (O2) at two liters by nasal cannula (NC, a lightweight tube which on one end splits into two prongs which are placed in the nostrils to deliver supplemental oxygen) to maintain oxygen saturations (oxygen levels) above 90 percent (%);
-Budesonide (a steroid medication) inhalation suspension 0.5 milligrams (mg) in two milliliters (ml), one vial inhaled orally two times each day;
-Ipratropium/Albuterol Solution (medications that help to open up the airways) 0.5/2.5 mg in 3 ml, inhale 3 ml orally two times daily.
Review of the resident's care plan, dated 03/30/23, showed the following:
-Focus: the resident has a diagnosis of asthma;
-Goal: the resident will remain free from complications of asthma through the next review date;
-Interventions: give nebulizer treatments and oxygen therapy as ordered.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, dated 04/01/23, showed the following:
-Cognitively intact;
-Diagnoses of asthma (a respiratory condition marked by spasms in the airways of the lungs, causing difficulty breathing), chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing) and respiratory failure (a condition that makes it difficult to breathe);
-Requires oxygen therapy.
Observation on 05/15/23 at 10:10 A.M. showed the following:
-The resident lay in his/her bed, awake, oxygen delivered via a nasal cannula (NC) at two liters (2L) from an oxygen concentrator (a medical device that delivers almost pure oxygen through the nasal cannula tubing), oxygen tubing was not labeled with date of application;
-A nebulizer mask (a mask that covers the mouth and nose and is held onto the face using an elastic band, used to deliver medications via an inhalation method to the lungs) was attached to tubing that was connected to a nebulizer machine (a small machine that turns liquid medication into a mist that can be easily inhaled). The nebulizer mask lay on the bedside table. The tubing and mask were not labeled with the date of application and not in a plastic bag.
During an interview on 05/15/23 at 10:10 A.M., the resident said the following:
-He/She wore oxygen all of the time;
-He/She had a history of lung problems and also used nebulized treatments that helped his/her breathing;
-He/She thought housekeeping staff changed his/her oxygen tubing once a week.
Observation on 05/16/23 at 2:50 P.M. showed the following:
-The resident lay in his/her bed and received oxygen via NC tubing at 2L from the oxygen concentrator. The oxygen tubing was not labeled with date of application;
-A nebulizer mask was partially wrapped in a brown paper towel and lay inside an open plastic bag on the bedside table. The tubing from the mask was attached to the nebulizer machine and was also on the bedside table. The mask and tubing were not labeled with the date of application.
Observation on 05/17/23 at 6:10 A.M. showed the following:
-The resident lay in his/her bed and received oxygen via NC tubing at 2L from the oxygen concentrator. The oxygen tubing was not labeled with date of application;
-A nebulizer mask was partially wrapped in a brown paper towel and lay inside an open plastic bag on the bedside table. The tubing from the mask was attached to the nebulizer machine and was also on the bedside table. The mask and tubing were not labeled with the date of application.
Observation on 05/18/23 at 8:25 A.M. showed the following:
-The resident lay in his/her bed and received oxygen via NC tubing at 2L from the oxygen concentrator. The oxygen tubing was not labeled with date of application;
-A nebulizer mask was partially wrapped in a brown paper towel and lay inside an open plastic bag on the bedside table. The tubing from the mask was attached to the nebulizer machine and was also on the bedside table. The mask and tubing were not labeled with the date of application.
Review of the resident's medical record showed no documentation to show when staff changed the resident's nasal cannula oxygen tubing or nebulizer mask and tubing.
2. Review of Resident #39's POS, dated 12/30/22, showed the following:
-Oxygen (O2) at three liters (3L) by nasal cannula (NC), if oxygenation level is below 90% as needed;
-Xopenex (levalbuterol, a medication used to help relax the muscles in the lungs and open up the airways), 0.31 mg/3 ml via nebulized solution three times daily as needed;
-Perforomist (formoterol, a medication used to help relax the muscles in the lungs and open up the airways), one vial by nebulized inhalation two times daily;
-Abuterol (a medication used to help open up the airways of the lungs), 2.5 mg/3 ml, 3 ml. by nebulized solution two times daily;
-Budesonide (a steroid medication that can help reduce inflammation in the lungs) inhalation suspension 0.5 milligrams (mg) in two milliliters (ml), one vial inhaled orally two times each day.
Review of the resident's care plan, dated (revised) 08/21/21, showed the following:
-Focus: the resident has COPD;
-Interventions: give aerosol or bronchodilators (medications that help to open up the airways of the lungs) as ordered. Give oxygen therapy as ordered by the physician.
Review of the resident's care plan, dated (revised) 08/26/21, showed the following:
-Focus: the resident has oxygen therapy;
-Interventions: If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (for example, changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with no assistance required for bed mobility, transfers, dressing, toileting, and personal hygiene;
-Required oxygen therapy.
Observation on 05/15/23 at 1:45 P.M. showed the following:
-The resident lay in his/her bed on his/her left side with his/her eyes closed;
-Oxygen tubing with a nasal cannula device was curled up on the wheelchair seat beside the resident's bed and was connected to a portable oxygen tank attached to the wheelchair. The oxygen tank was in the off position. The oxygen tubing was not labeled with the date of application and was not stored in a plastic bag.
-A nebulizer mask with tubing curled up lay open on the resident's bedside table and was not labeled with the application date or stored in a plastic bag.
Observation on 05/16/23 at 8:45 A.M. showed the following:
-Oxygen tubing with a nasal cannula device was curled up on the wheelchair seat beside the resident's bed and was connected to a portable oxygen tank attached to the wheelchair. The oxygen tank was in the off position. The oxygen tubing was not labeled with the date of application and was not stored in a plastic bag.
-The resident transferred himself/herself from the bed to the wheelchair and sat on the oxygen tubing and nasal cannula;
-Staff entered the room and placed a new, sealed, updraft nebulizer mask with tubing on the resident's nightstand. The sealed bag was not dated.
Observation on 05/16/23 at 2:45 P.M. showed the following:
-The resident lay on his/her bed with both eyes closed;
-The resident wore oxygen per nasal cannula tubing that was connected to a portable oxygen tank on his/her wheelchair at the bedside. The oxygen on at 2L. The oxygen tubing was not labeled;
-Nebulizer mask and tubing lay open on the nightstand and were not labeled with a date or stored in a plastic bag.
Observation on 05/18/23 at 8:25 A.M. showed the following:
-The resident lay in his/her bed and wore oxygen by a nasal cannula connected to an oxygen concentrator that was set at 2L;
-The oxygen tubing was not labeled with a date of application;
-A nebulizer mask lay on a brown paper towel on the resident's nightstand, connected to tubing that was curled up on a hand-hand mirror. The tubing was not labeled with a date or stored in a plastic bag.
During an interview on 05/18/23 at 8:25 A.M., the resident said the following:
-He/She wore oxygen most of the time and used a breathing machine regularly as he/she was short of breath with activity;
-He/She thought the staff changed the tubing on his/her oxygen and breathing machine but he/she was not sure when this occured.
Review of the resident's medical record showed no documentation to show when staff changed the resident's nasal cannula oxygen tubing or nebulizer mask and tubing.
3. Review of Resident #44's POS, dated 08/19/22, showed the following:
-Resident may wear O2 at up to three liters by NC to maintain oxygen saturations when less than 92%;
-Budesonide (a steroid medication that can help reduce inflammation in the lungs) inhalation suspension 0.5 mg in two ml, one vial inhaled orally two times each day;
-Aformoterol tartrate (a medication used to help relax the muscles in the lungs and open up the airways) nebulized solution, 15 micrograms (mc.) in two ml, one vial inhaled via nebulizer two times daily.
Review of the resident's care plan, dated (revised) 09/12/22, showed the following:
-Focus: the resident has COPD;
-Interventions: give nebulizer treatments and oxygen therapy as ordered;
-Focus: the resident has oxygen therapy related to COPD;
-Interventions: oxygen setting-to titrate (adjust) oxygen up to 3L via NC to maintain an oxygen concentration (when) less than 92%.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Medical diagnoses of COPD;
-Required oxygen therapy.
Observation on 05/15/23 at 10:25 A.M. showed the following:
-The resident sat up in his/her recliner at bedside;
-He/She wore a nasal cannula that was attached to an oxygen concentrator at the bedside. The concentrator was set at 2L. The oxygen tubing was not labeled with the application date;
-A nebulizer mask with tubing lay on the bedside table and was labeled 4/29 (17 days from the date of application);
During an interview on 05/15/23 at 10:25 A.M., the resident said the following:
-He/She wore oxygen all of the time;
-He/She received a breathing treatment morning and night;
-He/She was not sure if the staff changed the tubing because he/she cannot see well.
Observation on 05/16/23 at 2:45 P.M. showed the following:
-The resident lay in his/her bed with his/her both eyes closed;
-He/She wore oxygen by nasal cannula at 2L;
-His/Her oxygen tubing was not labeled with the application date;
-A nebulizer mask, partially wrapped in a brown paper towel, lay inside an open plastic bag, dated 5/8/23 (nine days from the date of application) on the resident's nightstand.
Observation on 05/18/23 at 8:50 A.M. showed the following:
-The resident lay in his/her bed with his/her eyes closed;
-He/She wore oxygen by nasal cannula at 2L;
-His/Her oxygen tubing was not labeled with the application date;
-A nebulizer mask, partially wrapped in a brown paper towel, lay inside an open plastic bag, dated 5/8/23 (11 days from the date of application) on the resident's nightstand.
Review of the resident's medical record showed no documentation to show when staff changed the resident's nasal cannula oxygen tubing or nebulizer mask and tubing.
4. Review of Resident #34's face sheet showed a diagnosis of COPD.
Review of the resident's care plan, dated 10/25/22, showed the following:
-The resident has COPD;
-Monitor vital signs, skin color, pulse oximetry, airway functioning and the degree of restlessness which may indicate hypoxia (lack of oxygen);
-The staff will monitor the resident for signs and symptoms of COPD exacerbation (worsening) and contact the physician as needed;
-No documentation showing the resident received oxygen.
Review of the resident's quarterly MDS, dated [DATE], showed the resident had shortness of breath when lying flat, respiratory disease, and oxygen therapy.
Observation on 05/16/23 at 8:22 A.M., showed the resident lay in his/her bed and received oxygen via NC. The oxygen tubing was not labeled with the date of application.
Review of the resident's medical record showed no documentation to show when staff changed the resident's nasal cannula oxygen tubing.
During an interview on 05/18/23 at 8:50 A.M., Registered Nurse (RN) C said the following:
-Licensed or unlicensed staff change the oxygen tubing and nebulizer masks and tubing every Saturday night;
-Oxygen and nebulizer tubing should be labeled, and the bags they are put in should be labeled too;
-The staff who change the tubing should label the tubing;
-He/She thought there was a clipboard on the nursing units where staff documented when they changed the tubing;
-He/She looked for the clipboard and could not find it.
During an interview on 05/18/23 at 10:50 A.M., the Director of Nurses (DON) said the following:
-Oxygen and nebulizer tubing and masks should be changed every week;
-Nightshift staff was responsible for changing/labeling the oxygen and updraft tubing and masks;
-The facility just started putting the tubing changes on the Treatment Administration Record (TAR) last week for the licensed staff to do. Prior to that, it was on a clipboard at the nurses' station and any staff could do it;
-Staff should clean updraft masks and tubing after each use. Staff clean them with warm water and allow them to air dry on a paper towel at the resident's bedside. When they are dry, they can be stored in a plastic bag.
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 accordance with professional standards for food service safety when it failed to refrigerate opened containers ...
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Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when it failed to refrigerate opened containers of food as specified by the manufacturer, discard food that was expired or showed visible signs of deterioration, appropriately store and handle food products to maintain quality and free from potential contaminants, and label and date opened food and beverage items. The facility also failed to ensure the range hood baffle filters were free of an accumulation of grease, vent covers and dish storage areas were free of dust and debris, and condensation from vents was not allowed to drip onto food surface areas. The facility census was 50.
1. Review of the facility's policy, implemented January 2023, Food Safety Requirements, showed the following:
-Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety;
-Food will be stored in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms;
-Foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable;
-Practices to maintain safe refrigerated storage include: labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded and keeping foods covered or in tight containers.
Review of the facility's undated policy, Date Marking for Food Safety, showed the following:
-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 seven days;
-The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded;
-The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared;
-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;
-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;
-The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly;
-The dietary manager shall spot check refrigerators weekly for compliance.
1. Observations on 5/16/23 at 8:29 A.M., 2:31 P.M., and 4:03 P.M. in the kitchen showed the following:
-Opened bottles of ranch dressing, parmesan cheese, chocolate syrup, applesauce, ketchup, mustard, and Worcestershire sauce sat in approximately 0.25 inches of clear liquid in a tray on the upper left shelf of the refrigerator located by the coffee/tea maker;
-Four 32-ounce clear plastic bags of frozen diced pepper and onion blend, with no manufacturer expiration date visible, located in the bottom left portion of the upright freezer located across from the walk-in refrigerator, showed an excess of ice crystals and freezer burn.
Observation on 5/16/23 at 8:52 A.M. and 10:53 A.M. of the dry storage room located near the kitchen showed the following:
-An unlabeled clear tote, approximately 1 foot by 2 foot by 3 foot in size, contained a dry white powder was located on the bottom shelf of a storage rack;
-A small clear bowl, covered with foil, labeled and dated flour 5-4 and located on a black cart, contained an approximate 2 inch crack in the foil which exposed the food contents to air;
-An opened, approximately half full gallon container of soy sauce, located on the bottom shelf of a storage rack, had a manufacturer's label that read, Refrigerate after opening for quality;
-Nine bags of 12-pack hot dog buns, dated 3/31/23, located on the bottom shelf of a metal enclosed cabinet. Blue-gray mold covered approximately 75% of the buns in one of the bags;
-Twelve bags of 12-pack hamburger buns, dated 3/7/23, was located on the top shelf of a metal enclosed cabinet and were firm to the touch;
-One 24.5-ounce package of flour tortillas, dated 3/22/23 and labeled 2-27 in marker, was located on the top shelf of a metal enclosed cabinet;
-One approximately half-full package of flour tortillas, in a gallon zipper bag was labeled 2-27 in marker and no visible manufacturer's expiration date, was located on the top shelf of a metal enclosed cabinet;
-Seventeen yellow hard taco shells, in a gallon zipper bag labeled hard taco 2-27 in marker and no visible manufacturer's label or expiration date, was located on the top shelf of a metal enclosed cabinet;
-Three 18.6-ounce packages of flour tortillas, labeled 3-21 with marker and a manufacturer's expiration date of 5/14/23, was located on the top shelf of a metal enclosed cabinet;
-A 59-ounce cardboard carton of dry mashed potatoes, with the top of the pour spout carton loosely closed, was labeled 10-7 with marker and a manufacturer's best by date of 3/31/23,
-One opened half-full 32-ounce bottle of lemon juice, was labeled 3-14 with marker and a manufacturer's label that read, Refrigerate after opening.
Observation on 5/16/23 at 9:31 A.M. of the cabinets located below the counter in the dining room near the kitchen, showed the following:
-Two clear sandwich bags of cookies were undated;
-An unopened 3.25-ounce bag of corn puffs, had a manufacturer's guaranteed fresh date of 7/12/22;
-An opened 3.25-ounce bag of corn puffs, with the top of the bag loosely folded over and not securely sealed, had a manufacturer's guaranteed fresh date of 5/3/22;
-An opened 16-ounce bag of pretzels, with the top of the bag loosely folded over and not securely sealed, had a manufacturer's best if used by date of 8/29/22;
-An opened 4.25-ounce bag of corn puffs, with the top of the bag loosely folded over and not securely sealed, had a manufacturer's guaranteed fresh date of 7/12/22;
-An opened 14.5-ounce bag of corn chips snacks, had the top of the bag loosely folded over and not securely sealed;
-An opened 12-ounce box of crackers, with the top of the bag in the box loosely folded over and not securely sealed, had a manufacturer's best when used by date of 5/9/23.
Observation on 5/16/23 at 2:26 P.M. showed the following in the East Clean Utility Room refrigerator freezer section:
-An unopened small container of chocolate Magic Cup, with a use by date of 2/24/22;
-Three unlabeled, undated, and unopened small plastic cups of frozen substance (one was tan in color and two were brown in color);
-An opened and undated plastic water bottle half full of a light tan-colored liquid that was frozen. The bottle was unlabeled;
-An opened package of roasted turkey, printed Use or Freeze by 4/21/23 with no initials identifying to whom it belonged;
-An unlabeled and undated sandwich bag that contained a frozen burrito;
-An unlabeled and undated silver plastic package with unknown food contents. The plastic package was twisted at the top and had an approximate 2 inch tear in it which exposed the contents to air.
During an interview on 5/16/23 at 2:37 P.M., the Dietary Manager said the facility's nursing staff monitored the East and [NAME] Hall refrigerators to ensure food was labeled, dated, and expired items were discarded. The activity director was responsible for the food in the cabinets below the counter in the dining room next to the kitchen.
2. Observation on 5/16/23 from 8:04 A.M. to 9:17 A.M. of the kitchen showed the following:
-A moderate buildup of yellow grease on the kitchen range hood baffle filter located above the deep fat fryer;
-A moderate buildup of gray fuzzy debris on the top portion and sides of a metal wire storage rack which contained metal bowls, plates, and mugs;
-A thick coating of dust and debris on an 8 inch by 8 inch ceiling vent cover and a 1 foot by 2 foot vent cover, both of which were located above the metal wire storage rack which contained metal bowls, plates, and mugs.
During an interview on 5/16/23 at 2:37 P.M., the Dietary Manager said the kitchen staff cleaned the range hood baffle filters every three days by scrubbing them in the four-compartment sink and then running them through the dishwasher. A company professionally cleaned the filters every three months. The facility's housekeeping staff were responsible for cleaning the ceiling vents and covers.
3. Observation on 5/16/23 from 11:38 A.M. to 12:03 P.M. showed the following:
-Staff served food on plates for residents from the steam table in the kitchen;
-The ceiling vent, located above the steam table, blew cold air and the vent cover contained ice accumulation and multiple hanging drips of water;
-Drips of the water from the vent occasionally dripped onto the steam table counter and also into an empty metal steam table pan that had recently contained pureed food;
-A pan of dinner rolls, partially covered by foil, sat on top of the steam table just beyond the empty pan that once contained pureed food. Staff served dinner rolls from the pan onto staff and resident meal plates by reaching under where the water occasionally dripped from the vent in order to reach the dinner rolls.
During an interview on 5/16/23 at 2:37 P.M., the Dietary Manager said the issue of the vent cover above the steam table dripping water down onto the steam table started around 5/13/23 and the maintenance director was looking into the issue.
4. During an interview on 5/16/23 at 4:06 P.M., the Dietary Manager said the following:
-She expected foods to be labeled and dated;
-She expected foods to be appropriately covered and sealed so that food contents were not exposed to the air;
-She expected foods to be discarded that were expired, molded, or showed signs of freezer burn;
-She expected foods that were labeled by the manufacturer indicating to refrigerate after opening or refrigerate for quality to be refrigerated;
-She expected range hood baffle filters to be free of grease buildup;
-She expected vent covers and dish storage racks to be free of dust and debris;
-She expected vents and vent covers to not be dripping water onto food preparation areas.
During an interview on 5/16/23 at 4:33 P.M., the Administrator said the following:
-He expected foods to be labeled and dated, and foods to be appropriately covered and sealed so that food contents were not exposed to the air;
-He expected foods to be discarded that were expired, molded, or showed signs of freezer burn;
-He expected foods that were labeled by the manufacturer indicating to refrigerate after opening or refrigerate for quality to be refrigerated;
-He expected range hood baffle filters to be free of grease buildup;
-He expected vent covers and dish storage racks to be free of dust and debris;
-He expected vents and vent covers to not be dripping water onto food preparation areas.
Jan 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure two residents (Residents #1 and #2), in a review of three sampl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure two residents (Residents #1 and #2), in a review of three sampled residents, were free from abuse when Certified Nurse Assistant (CNA) A was forceful and cursed at Resident #2 during care, and made derogatory comments and was forceful and restrained Resident #1 when assisting him/her to eat his/her meal. Both residents, who have dementia, were upset in response to the abuse at the time the abuse occurred. Nurse Aide (NA) B reported CNA A yelled at Resident #1, taunted the resident, told the resident he/she was crazy, and restrained the resident's arms and shoved the spoon in the resident's closed mouth. Resident #1 responded with crying, flinched as CNA A put the spoon to his/her mouth, and spit food at CNA A. The facility census was 54.
Review of the facility's undated policy, Abuse, Neglect and Exploitation, showed the following:
-It is the policy of this facility that each resident will be free from abuse, neglect, misappropriation of resident property and exploitation.
-No abuse or harm of any type will be tolerated;
-Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish;
-Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.
1. Review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE].
Review of the resident's baseline care plan, dated 1/10/23, showed the following:
-He/She had a history of confusion;
-He/She required assistance and setup with eating;
Review of the resident's January 2023 physician's orders showed the resident's diagnoses included disorientation and anxiety disorder.
Review of the facility's investigative summary, completed by the regional nurse consultant and provided on 1/19/23, showed the following:
-During a telephone interview, Nurse Aide (NA) B said he/she was headed to the kitchen to get something when he/she heard CNA A, using a high tone of voice yelling at the resident, taunting the resident, telling the resident he/she was crazy, restraining the resident's arms and shoving the spoon in the resident's closed mouth. The resident's head was moving at the time as well. CNA A told NA B to watch the resident flinch, he/she has been abused. The resident was spitting the food out. CNA A also told the resident that he/she had a higher IQ than the resident, too high to take care of him/her;
-NA B's written statement showed as he/she was walking past the dining room, he/she heard yelling from the dining room. He/She went in and started assisting another resident. He/She watched CNA A force feeding the resident. CNA A was restraining the resident by the arms and shoved food in the resident's mouth. The resident was informing CNA A that he/she was hurting him/her when he/she was restrained. CNA A continued to taunt the resident. CNA A made a comment of thinking the resident had been abused and continued to shove food in the resident's face making comments to NA B when the resident flinched. CNA A was using foul language when he/she was yelling at the resident;
-Dietary Staff C's written statement showed he/she saw the resident talking and CNA A feed him/her while the resident was speaking. He/She heard CNA A say (to the resident) he/she was going to talk to the resident's family member. CNA A told the resident ,you're the reason I don't like my job, and CNA A had a higher IQ (was smarter) to be working here.
-Dietary Staff D's written statement showed when passing the dining room door, he/she noticed CNA A was trying to feed the resident. The resident was refusing to eat and used his/her hands to block his/her mouth. CNA A and the resident argued back and forth;
-Licensed Practical Nurse (LPN) D's written statement showed after supper/end of shift, NA B told him/her that another CNA was feeding a resident in the dining room and the resident seemed anxious and upset and was crying;
-Upon completion of our investigation, the facility could find evidence to substantiate this alleged abuse. As a result, CNA A employment has been terminated.
During interviews on 1/16/23 at 8:40 A.M., and 11:15 A.M., NA B said she was going to the kitchen to get something for a resident when he/she heard CNA A yelling. When he/she entered the dining room, he/she saw CNA A yelling at the resident. CNA A was yelling at the resident, telling the resident he/she was being ridiculous. CNA A was restraining the resident by holding down the resident's hands and shoving food into the resident's mouth. The resident was crying and spit the food back out at CNA A. The resident told CNA A he/she was not hungry. CNA A told NA B he/she thought the resident had been abused, and then told NA B to watch as CNA A shoved the spoon into the resident's mouth and the resident flinched.
During an interview on 1/17/23 at 1:02 P.M., Dietary Staff C said he/she was bussing tables on 1/15/23 and was in and out of the dining room. He/She observed CNA A aggressively feeding the resident. As the resident was speaking, CNA A crammed the spoon into the resident's mouth. The resident was confused and tearful. CNA A told the resident he/she was the reason he/she did not like his/her job and that he/she had a higher IQ and shouldn't be working there.
During an interview on 1/16/23 at 3:25 P.M., Dietary Staff E said he/she was working in the kitchen on 1/15/23. CNA A was in the dining room trying to feed the resident. The resident was shaking his/her hands in front of his/her face. CNA A and the resident were arguing but he/she couldn't hear what they were saying.
During an interview on 1/16/23 at 11:35 P.M., LPN D said NA B reported to him/her that CNA A was feeding the resident too fast, and didn't feel like the situation was going well. NA B said the resident was upset and crying.
2. Review of Resident #2's January 2023 physician's orders showed the resident's diagnoses included altered mental status and dementia with behavioral disturbances.
Review of CNA G's written statement (obtained during the facility's investigation and provided on 1/19/23) showed on 12/27/22, he/she and CNA H were walking down the hall and heard CNA A and the resident arguing at a very high level. CNA G and CNA H walked in and saw the resident had CNA A in a headlock. The resident was screaming, No, please let me go to my room while CNA A was still forcefully trying to rip down the resident's pants. CNA H stepped in between the resident and CNA A.
Review of CNA H's written statement (obtained during the facility's investigation provided on 1/19/23) showed on 12/27/22, he/she and CNA G were walking down the hall and heard CNA A and the resident arguing very loudly. They walked into the room and saw the resident had CNA A in a headlock. The resident was saying, No, please let me go to my room while CNA A was still trying to forcefully take the resident's pants down. CNA H stepped between them. He/She was able to calm the resident and get him/her dressed for bed after CNA A left the room.
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment, dated 1/2/23, showed the following:
-Severe cognitive impairment;
-Physical behaviors directed towards other one to three days in the seven-day look back period;
-Did not reject care;
-Always continent of bowel and bladder.
Review of the resident's care plan, dated as last reviewed 1/5/23, showed the following:
-The resident has symptoms of dementia with behavioral issues;
-He/She has short and long-term memory deficit and may not remember some things;
-He/She has noticeable times of being anxious/agitated/upset with other elders and situations that may be due to his/her diagnosis of dementia with behavioral disturbances;
-When he/she has times of agitation, encourage him/her to either watch sporting events or go to social events that may be taking place, or encourage him/her with conversation to help get his/her mind off of what upsets him/her;
-He/She is able to complete most ADLs without any assistance. He/She is able to transfer independently, dress himself/herself and toilets without assistance.
Review of Nurse Assistant (NA) F's written statement, dated 1/16/23 (obtained during the facility's investigation provided on 1/19/23), showed on an unknown date, CNA A and NA F were in the resident's room. The resident had an accident and was trying to go to sleep in his/her dirty pants. The resident wasn't wanting to change his/her clothes. CNA A told the resident he/she had fucking shitty pants and needed changed. CNA A and the resident argued with each other.
During an interview on 1/16/23 at 11:25 A.M., NA F said approximately a couple weeks ago (specific date unknown), he/she and CNA A were in the resident's room. The resident had been incontinent and did not want to change. CNA A was cursing at the resident and antagonizing him/her. CNA A told the resident he/she fucking shit himself/herself, and was not fucking going to bed that way. The resident was upset. NA F got the charge nurse to intervene.
During an interview on 1/16/23 at 2:15 P.M., the Director of Nursing (DON) said the Assistant Director of Nursing (ADON) counseled CNA A for his/her tone of voice after an incident occurred with the resident. The nurse noticed CNA A's voice was elevated with the resident.
During an interview on 1/19/23 at 1:17 P.M., the regional nurse consultant said the facility found evidence through their investigation to substantiate the abuse.
Complaint MO212724
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
Report Alleged Abuse
(Tag F0609)
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 reported all allegations of abuse, including allegatio...
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 reported all allegations of abuse, including allegations involving two residents (Residents #1 and #2), in a review of three sampled residents, according to facility policy. The facility census was 54.
Review of the facility undated policy, Abuse, Neglect and Exploitation, showed the following:
-Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report abuse to the nursing home administrator. The nursing home administrator or designee will report abuse to the state agency per State and Federal requirements;
-The facility will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately but no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury to the state survey agency;
-Staff will receive education and demonstrate competency about resident mistreatment, neglect, and abuse upon first employment and at least annually or at any time a supervisor or any other employee notes an issue requiring further education. Training shall include (but not limited to): training on the abuse and neglect policies and procedures, how to report abuse without fear of reprisal, the definition of what constitutes resident mistreatment, neglect, or abuse, etc.
-It is the policy of the facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns and incidents without fear of reprisal or retribution;
1. Review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE].
Review of the resident's baseline care plan, dated 1/10/23, showed the following:
-He/She had a history of confusion;
-He/She required assistance and setup with eating;
Review of the resident's January 2023 physician's orders showed the resident's diagnoses included disorientation and anxiety disorder.
During interviews on 1/16/23 at 8:40 A.M., and 11:15 A.M., Nurse Assistant (NA) B said she was going to the kitchen to get something for a resident when he/she heard Certified Nurse Assistant (CNA) A yelling. When he/she entered the dining room, he/she saw CNA A yelling at the resident. CNA A was yelling at the resident, telling the resident he/she was being ridiculous. CNA A was restraining the resident by holding down the resident's hands and shoving food into the resident's mouth. The resident was crying and spit the food back out at CNA A. The resident told CNA A he/she was not hungry. CNA A told NA B he/she thought the resident had been abused, and then told NA B to watch as CNA A shoved the spoon into the resident's mouth and the resident flinched. He/She reported all of this to Licensed Practical Nurse (LPN) D, his/her charge nurse, who advised him/her to call the hotline.
During an interview on 1/17/23 at 1:02 P.M., Dietary Staff C said he/she was bussing tables on 1/15/23 and was in and out of the dining room. He/She observed CNA A aggressively feeding the resident. As the resident was speaking, CNA A crammed the spoon into the resident's mouth. The resident was confused and tearful. CNA A told the resident he/she was the reason he/she did not like his/her job and that he/she had a higher IQ and shouldn't be working there. He/She reported this to the cook, but the cook didn't hear him/her. He/She didn't report this to anyone else at the facility.
During an interview on 1/16/23 at 11:35 P.M., LPN D said NA B reported to him/her that CNA A was feeding the resident too fast, and didn't feel like the situation was going well. NA B said the resident was upset and crying. NA B said he/she offered to assist the resident so LPN D thought the situation was taken care of. NA B did not tell him/her CNA A was forcing the resident to eat or holding the resident's arms. He/She didn't believe what NA B reported was abuse. He/She told NA B that he/she could talk to the resident's nurse if anything else needed to be done.
2. Review of Resident #2's January 2023 physician's orders showed the resident's diagnoses included altered mental status and dementia with behavioral disturbances.
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment, dated 1/2/23, showed the following:
-Severe cognitive impairment;
-Physical behaviors directed towards other one to three days in the seven-day look back period;
-Did not reject care;
-Always continent of bowel and bladder.
Review of the resident's care plan, dated as last reviewed 1/5/23, showed the following:
-The resident has symptoms of dementia with behavioral issues;
-He/She has short and long-term memory deficit and may not remember some things;
-He/She has noticeable times of being anxious/agitated/upset with other elders and situations that may be due to his/her diagnosis of dementia with behavioral disturbances;
-When he/she has times of agitation, encourage him/her to either watch sporting events or go to social events that may be taking place, or encourage him/her with conversation to help get his/her mind off of what upsets him/her;
-He/She is able to complete most ADLs without any assistance. He/She is able to transfer independently, dress himself/herself and toilets without assistance.
Review of NA F's written statement, dated 1/16/23 (obtained during the facility's investigation provided on 1/19/23), showed on an unknown date, CNA A and NA F were in the resident's room. The resident had an accident and was trying to go to sleep in his/her dirty pants. The resident wasn't wanting to change his/her clothes. CNA A told the resident he/she had fucking shitty pants and needed changed. CNA A and the resident argued with each other.
During interviews on 1/16/23 at 11:25 A.M., on 1/19/23 at 11:56 A.M., and on 1/20/23 at 8:16 A.M., NA F said approximately a couple weeks ago (specific date unknown), he/she and CNA A were in the resident's room. The resident had been incontinent and did not want to change. CNA A was cursing at the resident and antagonizing him/her. CNA A told the resident he/she fucking shit himself/herself, and was not fucking going to bed that way. The resident was upset. NA F got the charge nurse to intervene. He/She did not report CNA A's cursing to the charge nurse. He/She was a new NA and had only worked at the facility a couple months. He/She had only received training regarding abuse and neglect through a web-based training when he/she was hired. He/She had never seen the facility's policy regarding abuse and neglect. Prior to 1/16/23, he/she did not know the chain of command for reporting abuse allegations. The back of his/her name badge says to report abuse to the administrator or DON or the Department of Health and Senior Services (DHSS). When he/she heard CNA A curse at Resident #2, he/she told the charge nurse to come help, but did not report the cursing. He/She did not know cursing was considered abuse. He/She was unsure if the training he/she received addressed cursing as abuse.
3. During an interview on 1/16/23 at 10:54 A.M., the administrator and Director of Nursing (DON) said no one had reported any allegations of abuse to them.
During an interview on 1/16/23 at 2:15 P.M., the DON said no one prior to 1/16/23 had reported CNA A cursing at residents. If staff were cursing at residents, she would expect staff to report it to her. LPN D told him/her that NA B reported CNA A was frustrated (on 1/15/23) and NA B stepped in and took over feeding the resident. LPN D said NA B did not report abuse to him/her. She would expect staff to report allegations of abuse to her or the administrator. This is on the back of staff's name tags.
During an interview on 1/20/23 at 1:07 P.M., the regional nurse consultant said the following:
-The staff's name badges say to notify the administrator, DON or DHSS with allegations of abuse;
-He/She believed NA B felt he/she reported the incident when he/she reported it to DHSS;
-The information on the back of the name badges creates some confusion as to whom to report allegations of abuse;
-LPN D was aware NA B reported the incident to DHSS.
During an interview on 1/26/23 at 12:46 P.M., the administrator said the following:
-CNAs should report abuse to the charge nurse, DON, administrator or the DHSS;
-Staff know they have the right to call DHSS, but can also report abuse allegations to the administrator;
-All staff know to report abuse and should discuss it with the DON or administrator if they are unsure if an incident is abuse;
-Staff receive web-based training that goes through the different types of abuse. The training provides different scenarios of abuse; he/she believes the training includes cursing;
-He would expect staff to report if they observed other staff cursing at residents.
Oct 2019
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
2. Observation and interview on 10/2/19, at 10:58 A.M., in the locked cabinet in the [NAME] hall medication room showed:
- Resident #48 had an empty wallet and a watch.
- Registered Nurse (RN) A said...
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2. Observation and interview on 10/2/19, at 10:58 A.M., in the locked cabinet in the [NAME] hall medication room showed:
- Resident #48 had an empty wallet and a watch.
- Registered Nurse (RN) A said the resident keeps his/her wallet and watch in the medication room when he/she leaves the facility with his/her family.
3. During an interview on 10/3/19, at 9:30 A.M., the Assistant Director of Nursing (ADON) said:
- She and the Director of Nursing (DON) were unaware of the resident's wallets in the medication room.
During an interview on 10/3/19, at 1:54 P.M., the DON said:
- Staff should not store residents' personal items in the medication room.
Based on observation and interview, the facility failed to assure staff kept residents' personal belongings, including a wallet with money and a watch, protected from loss or theft, which affected two of 13 sampled residents, (Residents #43 and #48). The facility census was 44.
The facility did not provide a policy for how to account for residents' personal belongings.
1. Observation and interview on 10/2/19, at 4:32 A.M., in the locked cabinet in the East hall medication room showed:
- A wallet with a white piece of paper with a rubber band around it. The piece of paper had Resident #43's name on it. Staff wrote 8/3/19, $65.00 in cash. On 9/7/19, the resident took $12.00 out; staff and the resident signed the piece of paper;
- Licensed Practical Nurse (LPN) B said the resident keeps his/her wallet in the medication room so he/she can have money when he/she wanted it.
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** 4. Review of Resident #34's quarterly MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Extensive assistance of one st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #34's quarterly MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Extensive assistance of one staff for all toileting;
- Incontinent of bowel and bladder;
- Diagnoses included: dementia, diabetes mellitus, anxiety disorder, and psychotic disorder.
Review of the resident's undated care plan showed:
- Focus: Incontinent at times;
- Intervention: keep me clean and dry; want to remain free of infection related to urinary status, provide peri care, and monitor for signs and symptoms of urinary tract infection (UTI).
Record review of the nurses' notes, dated [DATE], showed:
- Resident has been agitated today;
- New order for urine analysis (UA) with culture and sensitivity (C&S) received.
Review of the UA with C&S showed:
- Collected urine [DATE] at 1:06 P.M.;
- C&S reported on [DATE] at 12:28 P.M. with escherichia coli (E-coli, bacteria normally found in the intestines) indicating a UTI.
Review of the nurses' notes showed:
- [DATE] at 12:52 P.M.: UA results called to the physician and a message left for the nurse; also informed them the resident hollering out frequently and confused to time and place;
- [DATE]: resident has a UTI and waiting for physician to give orders for antibiotics; he/she continues to have behaviors likely related to UTI;
- [DATE]: resident yelling and hollering most of the night;
- [DATE] at 1:30 A.M.: the resident has been screaming and hollering through the night:
- [DATE] at 2:08 P.M.: received call from physician to start Bactrim DS (antibiotic to treat UTI) twice a day for seven days.
Review of the resident's physician order sheet (POS), dated [DATE], showed:
- Bactrim DS; started [DATE], in the evening.
During an interview on [DATE], at 2:00 P.M., Assistant Director of Nursing (ADON) said:
- Ordered UA with C&S should be collected within twenty four hours of receiving the order;
- Staff receive notification on their computers when labs have been completed;
- Staff should watch for outstanding labs to return to the facility;
- Staff should receive an order and start antibiotics with the same day;
- Antibiotics are kept in an emergency kit.
During an interview on [DATE], at 1:55 P.M., the Director of Nursing (DON) said:
- Staff should follow physician orders.
- Staff should collect and send UA with C&S to the lab within 24 hours of receiving the order.
- Staff should obtain an order and start antibiotics in the same day of receiving the lab results.
- Staff should use the emergency kit to start antibiotics if unable to receive from pharmacy.
Based on observations, interviews, and record review, the facility failed to ensure staff followed professional standards of care when staff failed to administer Flonase nasal spray (used to treat seasonal allergies), failed to administer Azopt eye drops (used to treat glaucoma, increased pressure within the eyeball causing gradual loss of sight) and failed to administer artificial tears (used for dry eyes) correctly for one of 13 sampled residents (Resident #24), failed to obtain an order to flush Resident #100's PEG tube (a tube placed in the stomach to provide a route to deliver nutrition) and failed to start antibiotics in a timely manner for Resident #34. The facility census was 44.
1. Review of the facility's undated Physician Orders and Administration Policy showed:
- All medications will be administered and orders will be followed as ordered by a health care professional authorized by the state to order medications.
- All physician orders will be signed and dated, including the facility standing orders.
Review of the facility's undated administering nasal spray policy showed, in part:
- Close the nostril that is not receiving the medication. Do this by gently pressing on that side of your nose;
- Gently insert the bottle tip into the other nostril;
- Breathe in deeply through that nostril as you squeeze the bottle. Remove the bottle and sniff once or twice;
- Repeat if directed. Wait at least ten seconds between sprays;
- Repeat the above steps in the other nostril.
Review of the manufacturer's guidelines for Flonase nasal spray, showed, in part:
- Blow your nose to clear the nostrils;
- Close one nostril. Tilt your head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the other nostril;
- Repeat in the other nostril.
Review of the facility's eye instillation policy, revised [DATE], showed, in part:
- The purpose is to examine the eye, to treat infections, and to apply local anesthetic;
- Wipe away any discharge, using a separate Kleenex or cotton ball on each eye;
- Instruct resident to look upward;
- Hold lower eyelid away from the eye to form a pouch;
- Drop the solution into the middle of the lower lid (do not touch eye with dropper);
- The hand holding the dropper may be steadied by resting on the resident's forehead;
- With finger, apply pressure to the inside corner of the eye (more near the eye) for about one minute;
- Close eye gently and instruct resident to keep eyes closed for a few minutes;
- Wait five minutes before instilling another eye medication.
Review of the website, www.webMD, on how to administer artificial tears, showed, in part:
- Tilt your head back, look up and pull down the lower eyelid to make a pouch;
- For drops, place the dropper directly over the eye and squeeze out one or two drops as needed;
- Look down and gently close your eye for one or two minutes.
Review of the website, www.webMD, on how to administer Azopt eye drops, showed, in part:
- Tilt your head back, look upward, and pull down the lower eyelid to make a pouch;
- Hold the dropper directly over your eye and place one drop into the pouch;
- Look downward and gently close your eyes for one to two minutes and place one finger at the corner of your eye (near the nose) and apply gentle pressure.
2. Review of Resident #24's physician order sheet (POS), dated October, 2019, showed:
- An order for Flonase suspension 50 micrograms (mcg), two sprays in both nostrils in the morning for nasal congestion;
- An order for Artificial Tear solution, instill one drop in both eyes three times a day for dry eyes;
- An order for Azopt suspension 1%, instill one drop in both eyes two times a day for glaucoma.
Review of the resident's medication administration record (MAR), dated [DATE], showed:
- Flonase suspension 50 mcg, two sprays in both nostrils in the morning for nasal congestion;
- Artificial Tear solution, instill one drop in both eyes three times a day for dry eyes;
- Azopt suspension 1%, instill one drop in both eyes two times a day for glaucoma.
Observation on [DATE], at 7:34 A.M., showed:
- Certified Medication Technician (CMT) A shook the bottle of Flonase nasal spray and administered two sprays to each nostril;
- CMT A did not have the resident blow his/her nose and did not close one side of the resident's nostril;
- CMT A administered one drop of Artificial Tears in the left eye, touched the eye dropper to the eyelid and applied lacrimal pressure (pressure applied to the inner eye) for 30 seconds, administered one drop in the right eye, touched the eye dropper to the eyelid and applied lacrimal pressure for 45 seconds;
- CMT A waited for five minutes then placed a finger in the corner of the resident's eye and administered one drop of Azopt in the resident's right eye, touching the tip of the eye dropper to the resident's eyelid, and applied lacrimal pressure for 28 seconds, administered one drop in the left eye, touching the eye dropper to the resident's eyelid, and applied lacrimal pressure for 35 seconds.
During an interview on [DATE], at 1:04 P.M., CMT A said:
- Should follow the manufacturer's guidelines for administering Flonase nasal spray,; have the resident blow his/her nose and hold one side of the nose closed during administration.
3. Review of the facility's undated enteral tube feeding via bolus policy, showed, in part:
- It is the policy of the facility to provide enteral feeding as ordered by the physician via bolus to ensure adequate nutrition for residents that are unable to maintain their nutrition orally;
- Obtain a physician's order to include the following information: flushes before and after bolus feeding, free water flush order.
Review of Resident #100's POS, dated [DATE], showed:
- An order for enteral feed five times a day for tube feeding, Osmolite 1.5 calorie 240 milliliter (ml) bolus;
- Diagnoses included dysphagia (difficult or discomfort in swallowing) following stroke.
Review of the resident's MAR, dated [DATE], showed:
- Enteral feed five times a day for tube feeding, Osmolite 1.5 calorie 240 ml bolus;
- Diagnoses included dysphagia following stroke.
Observation on [DATE], at 8:38 A.M., showed Licensed Practical Nurse (LPN) A did the following:
- Attached the syringe to the port, pulled back on the plunger and did not have any residual;
- Removed the syringe and plunger and reattached the syringe to the port;
- Poured 20 ml of water in the syringe and it would not go down by gravity. LPN A used the plunger to force the water down;
- Removed the syringe and the plunger from the port and reattached the syringe;
- Poured the Osmolite into the syringe, using the plunger to force the feeding down the tube, and then it went down by gravity;
- Flushed with 60 ml of water.
During an interview on [DATE], at 2:24 P.M., LPN A said:
- He/she thought the peg tube should have been flushed with 60 ml, 10 to 20 ml before the bolus and 60 ml after the bolus;
- He/she reviewed the resident's POS and MAR and did not see an order to flush the peg tube or how often;
- Should have an order to flush the peg tube.
During an interview on [DATE], at 1:54 P.M., the Director of Nursing (DON) said:
- There should be an order to flush the peg tube with the amount and how often.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff transferred residents in a same manner t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff transferred residents in a same manner to prevent accidents or potential for accidents when staff failed to follow manufacturer's guidelines during mechanical lift transfers for three of 13 sampled residents (Resident #17, #26 and #100). The facility census was 44.
Review of the facility's undated Mechanical Lift Transfer Policy showed:
- Provide maximum safety for both the residents residing in the facility and the staff working with residents; a no lift facility.
- Residents unable to bear any weight will be transferred safely with the mechanical lift device which has been assessed to be the right lift for the needs of each resident.
Review of the Drive Electric patient lift manufacturer's guidelines, dated 2015, showed:
- Apply sling under the resident and hook the straps of sling with the hanging bar;
- Lock rear casters, lift the patient by pressing the up button on the control handset;
- Lift patient until his/her feet will swing easily off the bed, keeping patient facing the attendant;
- Unlock rear casters and transfer patient to and above commode or wheelchair;
- Lock brakes of both lifter and commode or wheelchair;
- Press the down button on control handset to gradually lower the patient;
- During the descent, assist patient to attain correct sitting position;
- When lifting patient, make sure the base legs are in the most widely opened position and the rear caster brakes are engaged. This will prevent tipping.
1. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/19, showed:
- Severe cognitive impairment;
- Total dependence of two staff for activities of daily living (ADLs);
-Diagnoses included: seizure disorder, cerebral palsy (congenital disorder of movement, tone, and posture), quadriplegia (partial or total loss of use of all four limbs or torso), and aphasia (loss of ability to understand or express speech caused by brain damage).
Review of the resident's care plan, updated 8/9/19, showed:
- Focus: Difficulty with ADLs related to cerebral palsy, intellectual disabilities, and quadriplegia;
- Interventions: requires a Hoyer lift and two staff members assistance for transfers.
Observation on 10/1/19, at 1:50 P.M., showed:
- Certified Nurse Aide (CNA) D and CNA F applied a mechanical lift pad to the Drive Electric patient lift and applied to Drive lift sling bar.
- CNA F opened the legs to the lift wide around the recliner and applied one caster brake.
- He/she then raised the resident with the lift with one caster brake locked.
- CNA F then unlocked the one caster brake and CNA D helped guide the resident to the bed.
- CNA F locked one caster brake and lowered the resident to the bed.
During an interview on 10/1/19, at 2:05 P.M., CNA D said:
- He/she had been trained to lock the caster brakes when lifting and lowering a resident.
- He/she should have locked both caster brakes instead of just one.
2. Review of Resident #100's admission MDS, dated [DATE], showed:
- Cognitive skills moderately impaired;
- Required extensive assistance of two staff for bed mobility, transfers and toilet use;
- Upper and lower extremities impaired on one side;
- Had a Foley catheter (sterile tube inserted into the bladder to drain urine);
- Always incontinent of bowel;
- Diagnoses included stroke and hemiparesis (weakness on one side of the body).
Observation on 10/1/19, at 1:16 P.M., showed:
- CNA C opened the legs on the mechanical lift, placed it around the resident's recliner and did not lock the brakes on the lift;
- CNA D and CNA E hooked the resident up to the lift;
- CNA C backed away from the recliner with the legs of lift open and moved to the side of the bed;
- CNA C did not lock the brakes on the lift and lowered the resident onto the bed;
- CNA D and CNA E unhooked the resident from the lift.
During a telephone interview on 10/3/19, at 11:32 A.M., CNA C said:
- The brakes on the mechanical lift should have been locked but he/she did not know it.
3. Review of Resident #26's significant change in status MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Extensive assist of two plus staff for bed mobility and transfers;
- Diagnoses included: Dementia and lower extremity impairment on both sides.
Observation on 10/02/19 at 4:40 AM., showed:
- CNA G and CNA H placed the resident's wheelchair toward the end of the bed and placed the lift pad under the resident as he/she lay in bed.
- CNA H placed the lift lift legs under the resident's bed and did not lock the casters then instructed CNA G to place the lift pads into the green loops.
- After loop pad placement, CNA H used the Drive lift (power lift) and gently raised the resident above the bed in the lift pad.
- CNA G helped position the resident in the lift pad while CNA H moved the lift legs away from under the bed to allow placement of the resident above his/her wheelchair.
- CNA G and CNA H guided the resident into his/her wheelchair and unhooked the lift pad loops.
- CNA H said the resident had an injured foot (which was wrapped) and they now transfer him/her with the lift.
- CNA H said he/she been taught in nurse aide training both to lock and to not lock the lift legs when lifting a resident. No one at the facility had instructed him/her to locked or unlock the lift's legs during transfers.
- CNA G said he/she also had been taught both ways in nurse aide class and no one at the facility had instructed him/her on how they wanted the Drive lift legs; locked or unlocked, during transfers.
- CNA N said the power Drive lifts were fairly new to the facility.
4. During an interview on 10/3/19, at 1:54 P.M., the Director of Nursing said:
- The brakes on the mechanical lift should be locked unless moving with the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
3. Review of the the facility's undated Liberalized Medication Pass Policy showed:
- Synthroid (hormone that treats underactive thyroid) will be given at 6:00 A.M.
Review of the manufacturer's guideli...
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3. Review of the the facility's undated Liberalized Medication Pass Policy showed:
- Synthroid (hormone that treats underactive thyroid) will be given at 6:00 A.M.
Review of the manufacturer's guidelines, found at www.synthroid.com dated 2018, showed:
- Take Synthroid (used to treat underactive thyroid function) as a single dose, preferably on an empty stomach, one-half to one hour before breakfast.
- Products such as iron and calcium supplements can lower your bodies ability to absorb; should be taken four hours before or after these products.
Review of Resident #9's POS, dated September 2019, showed:
- Synthroid 50 micrograms (mcg) by mouth in the morning for hypothyroidism (underactive thyroid);
- Lamotrigine 25 milligrams (mg) by mouth in the morning for seizures;
- Occuvite multiple vitamins-minerals give 1 tablet by mouth in the morning for macular degeneration (eye disease that causes vision loss);
- Vitamin D 2000 international unit (IU) by mouth in the morning.
Observation on 10/2/19, at 8:30 A.M., showed:
- CMT B administered the following medications: Synthroid 50 mcg, Lamotrigine 25 mg, Occuvite 1 tab, and vitamin D 2000 IU to the resident with a glass of water.
During an interview on 10/2/19, at 9:30 A.M. CMT B said:
- Synthroid should be given at 6:00 A.M. and before breakfast.
During an interview on 10/3/19, at 1:55 P.M. the Director of Nursing (DON) said:
- Staff should administer Synthroid at 6:00 A.M. and before breakfast.
Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than five percent. Facility staff made four medication errors out of 29 opportunities for error which resulted in a medication error rate of 13.79%, which affected three of 13 sampled residents (Residents #24, #37 and #9). The facility census was 44.
Review of the facility's undated Medication Administration Policy showed:
- All medications will be administered as ordered by a physician in a safe and sanitary manner.
- Administer medications as specified by the manufacturer.
- Administer medications with adequate fluids as specified by the manufacturer including bulk laxatives.
1. Review of Resident #24's physician order sheet (POS), dated October 2019, showed:
- An order for Miralax powder, give 17 grams by mouth in the morning for constipation in 8 ounces of fluid or 240 milliliters (ml).
Review of the resident's medication administration record (MAR), dated October 2019, showed:
- Miralax powder, give 17 grams by mouth in the morning for constipation in 8 ounces of fluid.
Observation on 10/2/19, at 7:20 A.M., showed:
- Certified Medication Technician (CMT) A measured out 17 grams and placed in a clear plastic cup, added 120 ml or 4 ounces of water and administered it to the resident;
- The resident drank all of it.
During an interview on 10/2/19, at 1:04 P.M., CMT A said:
- If the order said mix in 8 ounces of fluid, then it should have been mixed with 8 ounces of fluid.
During an interview on 10/3/19, at 1:54 P.M., the Director of Nursing (DON) said:
- Staff should follow the physician's orders and mix with 8 ounces of fluid.
2. Review of the facility's undated insulin pen administration policy, showed, in part:
- Priming the insulin pen: dial two units by turning the dose selector clockwise. With the needle pointing up, push on the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat this procedure until at least one drop of insulin appears;
- Setting the insulin dose: turn the dose selector to ordered dose, a click will be heard for each unit dialed. If an incorrect dose has been set, dial the dose selector forward or backward until the correct number of units has been set.
Review of instructions for use of Novolog Flexpen (fast acting insulin), revised December 2018, showed Novolog Flexpen is designed to used with Novofine, Novofine plus, or Novotwist needles. Giving the airshot before each injection:
- Before each injection small amounts of air may collect in the cartridge during normal use.
- To avoid injecting air and to ensure proper dosing: turn the dose selector to two units, hold your Novolog Flexpen with the needle pointing up.
- Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge.
- Keep the needle pointing upwards, press the push button all the way in.
- The dose selector returns to zero.
- A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times.
Review of the manufacturer's guidelines for Novolog insulin, showed, in part:
- Inject Novolog insulin five to ten minutes before a meal into the abdominal area, thigh, buttocks or upper arm.
Review of the undated quick reference guide for Lantus Solostar insulin (long acting insulin), showed, in part:
- Always do a safety test before each injection to remove air bubbles and make sure that the pen and needle are working properly;
- Select a dose of two units;
- Hold the pen with the needle pointing upward and press the injection button all the way in;
- Check if insulin comes out of the needle.
Review of Resident #37's POS, dated October 2019, showed:
- An order for Novolog insulin, 3 units before meals for diabetes mellitus;
- An order for Novolog insulin Flexpen, inject per sliding scale before meals and at bedtime, 251 to 400, give 4 units for diabetes mellitus;
- An order for Lantus insulin, 6 units in the morning for diabetes mellitus.
Review of the resident's MAR, dated October 2019, showed, in part:
- Lantus insulin 6 units every morning for diabetes mellitus;
- Novolog 3 units before meals for diabetes mellitus;
- Novolog Flexpen per sliding scale before meals and at bedtime, 251- 400- 4 units for diabetes mellitus.
Observation and interview on 10/2/19, showed:
- 7:12 A.M., Licensed Practical Nurse (LPN) A obtained the resident's blood sugar of 299;
- 7:13 A.M., LPN A attached a new needle to the Novolog Flexpen, turned the dial to 8, said he/she primed with 1 unit and administered 7 units;
- 7:16 A.M., LPN A attached a new needle to the Lantus insulin pen, turned the dial to 7, said he/she primed with 1 unit and administered 6 units;
- 8:53 A.M., staff delivered the resident's room tray and he/she started feeding him/herself.
During an interview on 10/2/19, at 1:24 P.M., LPN A said:
- He/she should have primed the insulin pens with 2 units;
- The resident should have a meal within 15 to 30 minutes after they get their insulin.
During an interview on 10/3/19, at 1:54 P.M., the DON said:
- The policy said to prime with 2 units;
- Staff should not include priming the insulin pen with the dose to be administered;
- The resident should have a meal within 15 minutes after receiving Novolog.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staff properly stored and discarded stock medications in the medication room and disposed of loose pills in the medica...
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Based on observation, interview, and record review, the facility failed to ensure staff properly stored and discarded stock medications in the medication room and disposed of loose pills in the medication cart; failed to label liquid morphine sulfate (narcotic pain medication) with an open date for one of 13 sampled residents (Resident #26). This had the potential to affect any resident who required the stock medication and multi-dose bottles of medication. The facility census was 44.
Review of the facility's undated Medication Storage Policy showed:
- All medications will be stored per manufacturer's recommendations.
- Medication expiration dates will be checked prior to use.
- Any medications noted to be expired will be destroyed per facility policy.
1. Observation and interview on 10/2/19, at 4:32 A.M., in the East hall medication room:
- Three bisacodyl suppositories for constipation, expired April 2019;
- 24 bisacodyl suppositories for constipation expired June 2019;
- One opened bottle of Naproxen 220 milligrams (mg), used for pain, expired August 2019;
- Licensed Practical Nurse (LPN) B said he/she thought the Assistant Director of Nursing (ADON) and the certified medication technician (CMT) checked for expired medication and all the nurses and CMTs check the medication when they are passing medication. Should not use expired medications; they should be wasted;
- Four loose round red pills, one loose oval yellow pill, one loose oblong pink pill, one loose round brown pill, and four loose round white pills in the East hall medication cart;
- LPN B said the loose pills should be wasted.
3. Observation and interview on 10/2/19, at 9:50 A.M., in the [NAME] medication room showed:
- Resident #26's liquid morphine sulfate multi-dose medication not labeled when opened;
- Registered Nurse (RN) A said all multi-dose bottles of medication should be labeled when opened including liquid morphine sulfate.
During an interview on 10/3/19, at 1:54 P.M., the Director of Nursing (DON) said:
- Did not have staff assigned to check for expired medications;
- The pharmacist periodically sends someone to check for expired medications;
- Staff should check for expired medications during the medication pass;
- Staff should not use the expired medications, they should bed destroyed.
- Staff should label multi-dose bottles of medications when opened including morphine sulfate.
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
This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated 10/25/19.
Based on observation, record review and interview, the facility failed to prepare f...
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This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated 10/25/19.
Based on observation, record review and interview, the facility failed to prepare food in a safe manner in accordance with professional standards for food service safety when they failed to follow their policy for food preparation and handling to discard foods that stand for several hours at room temperature when staff let raw chicken set uncovered on the counter with no way to ensure it did not fall into the danger zone (food temperatures between 41 degree Fahrenheit (F) and 135 degree F) from 9:25 A.M. to 12:20 P.M. The raw chicken's internal temperature reached 51 to 59 degrees F during the noon meal preparation before cooking the chicken to serve the residents. This practice affected all residents who consumed the fried chicken. The facility had a census of 45.
1. Review of the undated facility's Food Preparation and Handling Policy showed:
- The danger zone for food temperatures is between 41 degree Fahrenheit (F) and 135 degree F. This temperature range promotes rapid growth of pathogenic microorganisms that cause foodborne illness.
- Potential hazardous food include poultry, eggs and milk.
- The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained below 41 degree F or above 135 degree F; potentially hazardous foods held in the danger zone for more than 4 hours at room temperature may cause foodborne illness.
- Foods that stand for several hours at room temperature cannot be considered safe and free from contamination and cannot be made so by refrigeration. The foods will be discarded.
Observation and interview during the initial tour of the kitchen on 12/4/19, at 9:25 A.M., showed the Dietary Manager (DM) went into the walk in refrigerator and removed an 8 inch deep pan of thawed raw chicken. The DM said they would deep fat fry the boneless chicken thighs closer to the meal time. She was checking the pan of chicken to make sure they had enough pieces. She sat the pan of chicken directly on the counter. The pan of raw chicken was not on ice and had no way to keep the chicken below 41 degrees F.
Observation on 12/4/19, starting at 10:20 A.M., showed the following:
- At 10:20 A.M., three pans sat directly on the counter; an 8 inch deep pan of raw chicken thighs, a shallow pan containing a mixture of egg and milk (egg wash) and a shallow pan of seasoned bread crumbs (crumb coat); the pan of raw chicken did not sit in any ice to keep the temperature out of the danger zone;
- At 10:30 A.M., the Dietary Manager (DM) instructed [NAME] A to use the deep fat fryer to fry the chicken; then the DM went into the store room and closed the door;
- At 10:40 A.M., [NAME] A dredged (dipped and covered) four chicken thighs into the egg wash, then into the crumb coat and placed two pieces of chicken into each fryer basket of the deep fat fryer. [NAME] A said it would take less than 15 minutes to fry chicken in the deep fat fryer.
- At 10:52 A.M., [NAME] A raised the basket and placed the baskets into the holding notch above the deep fat fryer and checked the temperature of the first basket of chicken at 172 degrees; then raised the second basket;
- At 11:08 A.M., [NAME] A dredged four more pieces of chicken in the egg wash then into the crumb coat;
- At 11:11 A.M., [NAME] A placed the four pieces of chicken from the deep fat fryer baskets into a steam pan located on the steam table;
- At 11:15 A.M., [NAME] A dredged four more pieces of chicken into the egg wash and into the crumb coat, leaving the raw chicken in an single layer in the pan of crumbs;
- At 11:18 A.M., observation showed the pan of raw chicken on the counter contained bloody water covering about half of the chicken;
- At 11:20 A.M., [NAME] A checked the chicken in the deep fat fryer, took the temperature of the chicken, which measured 170 degrees then placed the chicken in the food processor and pureed the chicken; [NAME] A asked [NAME] B to go ask the DM if she could help. No chicken was in the deep fat fryer at this time; the raw chicken remained on the counter either in the pan of raw chicken or in a single layer in the crumb pan;
- At 11:28 A.M., the DM returned from the storage room and placed two pieces of chicken from the breaded chicken into the deep fat fryer, then breaded several more pieces of chicken leaving the raw breaded chicken single file in the shallow crumb pan;
- At 11:32 A.M., [NAME] A placed the pureed chicken into the oven;
- At 11:50 A.M., the DM removed chicken from the deep fat fryer, placed the chicken into the steam table and placed the four pieces of chicken from the crumb pan into each deep fat fryer basket. The DM said she needed to cook the chicken to at least 165 degree F.
- At 11:52 A.M., the DM dredged more raw chicken and left the chicken in a single layered in the crumb pan;
- At 12:10 P.M., after being asked to check the temperature of raw chicken, the DM had [NAME] A hand the thermometer to the surveyor to use; the DM verified the temperature of the raw breaded chicken located in the crumb pan at 59 degree F and the raw chicken in the half filled pan of raw chicken at 50 degrees F;
- At 12:15 P.M., the DM disposed of four pieces of chicken that were 59 degrees F from the crumb pan by placing the pan of chicken in the dirty dish area; the remaining pieces of raw chicken with a temperature of 50 degrees F remained on the counter.
- At 12:20 P.M., the DM placed the pan of raw chicken under a shallow pan of ice, set up a new pan of crumb coat and continued frying chicken. Dietary staff did not take the temperature of the chicken prior to meal service.
During an interview on 12/4/19, at 2:30 P.M., the Administrator said the DM was not available for interview as she was not in the building and not available by phone.
During an interview on 12/4/19, at 3:10 P.M., [NAME] B said the DM placed a deep pan of raw thawed chicken on the counter earlier this morning before he/she prepared breakfast and he/she put it back into the cooler sometime during breakfast preparation. He/She did not remember how long the chicken was on the counter during breakfast preparation. The DM brought the chicken back out of the refrigerator and placed it on the counter while he/she was doing dishes, which was probably between 9:00 A.M., and 10:00 A.M He/she was unaware how long the raw chicken had been on the counter before he/she placed the pan of raw chicken back into the refrigerator during breakfast. After lunch, he/she tossed the four pieces of breaded raw chicken the DM had placed by the trash can, but had not disposed of any raw chicken.
During an interview on 12/4/19, at 3:30 P.M., [NAME] A said he/she had no idea how long the chicken sat on the counter prior to him/her starting to fry chicken after he/she came to work at 10:30 A.M. Until this morning, he/she came to work at 8:00 A.M., and oven fried chicken. He/she did not understand why the DM instructed him/her to use the deep fat fryer this morning since it took too long to fry small batches of chicken. He/she was unsure if the chicken the DM placed over a pan of ice was the same chicken that had been on the counter all morning. He/she did not see the DM dispose of any of the raw chicken that had been on the counter.
Observation and interview on 12/4/19, at 3:45 P.M., the Administrator said he hoped the chicken that was fried after the warm chicken temperature was determined was a new pan of chicken. He checked the kitchen trash and found no raw uncoated chicken. He said the DM had a culinary degree and knew better than to leave raw chicken on the counter most of the morning. The DM knew better than to continue cooking raw chicken after the temperature was discovered out of the safe zone
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $76,961 in fines. Review inspection reports carefully.
- • 22 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $76,961 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (23/100). Below average facility with significant concerns.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Pioneer Skilled Nursing Center's CMS Rating?
CMS assigns PIONEER SKILLED NURSING CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Pioneer Skilled Nursing Center Staffed?
CMS rates PIONEER SKILLED NURSING CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 53%, compared to the Missouri average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Pioneer Skilled Nursing Center?
State health inspectors documented 22 deficiencies at PIONEER SKILLED NURSING CENTER during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 20 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 Pioneer Skilled Nursing Center?
PIONEER SKILLED NURSING CENTER 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 AMERICARE SENIOR LIVING, a chain that manages multiple nursing homes. With 96 certified beds and approximately 50 residents (about 52% occupancy), it is a smaller facility located in MARCELINE, Missouri.
How Does Pioneer Skilled Nursing Center Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, PIONEER SKILLED NURSING CENTER's overall rating (2 stars) is below the state average of 2.5, staff turnover (53%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Pioneer Skilled Nursing Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Pioneer Skilled Nursing Center Safe?
Based on CMS inspection data, PIONEER SKILLED NURSING CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Pioneer Skilled Nursing Center Stick Around?
PIONEER SKILLED NURSING CENTER has a staff turnover rate of 53%, which is 7 percentage points above the Missouri average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Pioneer Skilled Nursing Center Ever Fined?
PIONEER SKILLED NURSING CENTER has been fined $76,961 across 2 penalty actions. This is above the Missouri average of $33,848. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Pioneer Skilled Nursing Center on Any Federal Watch List?
PIONEER SKILLED NURSING CENTER 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.