OSAGE BEACH REHABILITATION AND HEALTH CARE CENTER
For profit - Corporation
94 Beds
NATIONAL HEALTHCARE CORPORATION
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
6/100
#185 of 479 in MO
Photo by Osage Beach Rehab & Health Care Center
Photo by Osage Beach Rehab & Health Care Center
Photo by Osage Beach NHC
1 / 5 photos
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Osage Beach Rehabilitation and Health Care Center has received a Trust Grade of F, which indicates significant concerns about the facility's quality of care. Ranked #185 out of 479 nursing homes in Missouri, it is still in the top half, but the overall rating suggests there are many areas for improvement. The facility is currently worsening, with issues increasing from 2 in 2024 to 9 in 2025. Staffing is relatively strong with a 4/5 star rating and a turnover rate of 48%, which is better than the state average, indicating that staff members tend to stay longer and are familiar with residents. However, the facility has concerning fines totaling $135,209, which are higher than 92% of other Missouri facilities, suggesting ongoing compliance issues. Recent inspections revealed critical shortcomings, including failures in infection control practices that put residents at risk of contracting Covid-19 and accidents during resident transfers that resulted in injury. These incidents highlight serious safety concerns alongside the facility's strengths in staffing and RN coverage, which is better than 94% of state facilities. Families should weigh both the positive aspects and these significant risks when considering this nursing home for their loved ones.
- Trust Score
- F
- In Missouri
- #185/479
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $135,209 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 48 minutes of Registered Nurse (RN) attention daily — more than average for Missouri. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
6/100
Top 38%
Review needed
2 → 9 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 2 issues
2025: 9 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Above Missouri average (2.5)
Meets federal standards, typical of most facilities
Staff Turnover: 48%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Federal Fines: $135,209
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: NATIONAL HEALTHCARE CORPORATION
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
2 life-threatening 3 actual harm
Jun 2025
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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when the lift hit a television ...
Read full inspector narrative →
Based on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when the lift hit a television mounted on the wall and the television fell and struck the resident and he/she sustained an injury to his/her head and arm. The facility census was 77.
1. Review of the Electric Portable Patient Lift owner's operator and maintenance manual, undated, showed the guide recommends two persons transfer in circumstance of combativeness, obesity, contracture etc. It is the responsibility of each facility or medical professional to determine if a one or two person transfer is more appropriate.
Review of the facility's Transfers and Lifts policy, undated, showed the lift must be used with two staff members.
2. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool, dated 6/5/25, showed staff assessed the resident as follows:
-Cognitively intact;
-Totally dependent for transfer assist with two or more staff;
-Paraplegia (muscle weakness or paralysis on the lower half of the body);
-Obesity;
-Utilized wheelchair for mobility.
Review of the residents plan of care, dated 12/18/24, showed staff assessed the resident as required the use of the mechanical lift for all transfers with two person assist.
Review of the resident's nurse notes, late entry on 6/17/25, showed staff documented on 6/13/25 at 6:30 P.M,. Certified Nursing Assistant (CNA) A reported the television (TV) in the residents room fell off the wall while transferring the resident to bed from the wheelchair. CNA A reported the TV did not hit the resident and there were no red marks/areas on the resident and the resident denied pain.
During an interview on 6/17/25 at 9:46 A.M., the resident said CNA A had him/her in the mechanical lift with no other staff present and the mechanical lift struck the TV on the wall and came down and hit him/her in the head and the arm. He/She told CNA A it hit him/her in the head and he/she felt the knot on his/her head and said he/she would get help. He/She said staff often only use one staff assist when they utilize the mechanical lift and that concerns the resident because he/she is paralyzed.
During an interview on 6/17/25 at 10:39 A.M., Registered Nurse (RN) B said he/she was told by CNA A the TV fell off the wall during a transfer but did not hit the resident. He/She said he/she worked the next day and the resident never said anything further to him/her. He/She said he/she was not aware if CNA A had performed the mechanical lift on his/her own or had staff present but it is policy to always have two staff present during a mechanical lift.
During an interview on 6/17/25 at 10:47 A.M., CNA A said he/she was raising the mechanical lift to assist the resident to bed and the top of the lift hit the TV and the TV came off the wall. He/She said he/she saw the TV hit the residents arm and the resident said it hit his/her head. He/She said he/she checked the residents head and there was no swelling. He/She said he/she reported the incident to RN B and told him/her it hit the residents arm and his/her head. He/She said he/she was operating the mechanical lift by him/herself. He/She said they always try to have two staff during mechanical lifts. CNA A said he/she couldn't remember why her/she did not have another staff in the room to assist with the mechanical lift transfer.
MO00255879
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interviews and record review, facility staff failed to notify the physician in a timely manner of an injury to one resident (Resident #1) when a television fell from the wall and struck the r...
Read full inspector narrative →
Based on interviews and record review, facility staff failed to notify the physician in a timely manner of an injury to one resident (Resident #1) when a television fell from the wall and struck the resident in the arm and head. The facility census was 77.
1. Review of the facility's change in patient status Policy, revised 3/2024, showed the charge nurse is to notify the physician.
Review of the facility's Accidents and Untoward Occurrences Policy, reviewed May 2025, showed staff are directed to notify the physician and document content of discussion.
2. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool, dated 6/5/25, showed staff assessed the resident as follows:
-Cognitively intact;
-Guillain-Barre syndrome (immune system attacks the nerves), Paraplegia (muscle weakness or paralysis on the lower half of the body).
Review of the resident's nurse notes, late entry on 6/17/25, showed staff documented on 6/13/25 at 6:30 P.M,. Certified Nursing Assistant (CNA) A reported the TV in the residents room fell off the wall while transferring resident to bed from his/her wheelchair. CNA A reported the TV did not hit the resident and there were no red marks/areas on the resident and reported no pain. Review of the residents nurses notes did not contain documentation staff notified the physician of the change in condition.
During an interview on 6/17/25 at 10:39 A.M., Registered Nurse (RN) B said he/she should have called to notify the physician. He/She said he/she did not realize the resident was struck by the television.
During an interview on 7/2/25 at 8:08 A.M., the Director of Nursing (DON) said he/she expects all staff to notify the physician of any accidents, especially involving the head. He/She said the rule is when in doubt, call the physician and document. He/She said he/she does not know why the nurse did not call the physician.
During an interview on 7/2/25 at 10:02 A.M., the administrator said he/she expects the nurse to assess any accidents and to consult with the physician to see what to do. He/She does not know why the physician was not contacted.
MO00255879
Feb 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation and interview, facility staff failed to ensure residents' personal information was protected when staff left the computer screen open in public areas for six residents (Resident #...
Read full inspector narrative →
Based on observation and interview, facility staff failed to ensure residents' personal information was protected when staff left the computer screen open in public areas for six residents (Resident #7, #26, #31, #61, #74 and #79) of nine sampled residents. The facility's census was 75.
1. Review of the facility's policy titled, National Healthcare Corporation (NHC) Health Insurance Portability and accountability Act (HIPAA) Privacy Program, dated 12/2024, showed:
-NHC is committed to complying with the HIPAA Privacy Rule and maintaining the confidentiality of patient's Protected Health Information (PHI) through appropriate, authorized access, uses, and disclosures;
-NHC creates, stores, maintains, uses, transmits, collects and disseminates PHI in an environment that promotes confidentiality and integrity without compromising PHI.
2. Observation on 02/24/25 at 7:45 A.M., showed Registered Nurse (RN) A left the computer screen open and unattended on with Resident #31 medication information visible in Hallway A. Observation showed residents and staff walked by the cart.
Observation on 02/24/25 at 8:00 A.M., showed RN A left the computer screen open and unattended with Resident #26 medication information visible in Hallway A. Observation showed residents and staff walked by the cart.
Observation on 02/24/25 at 8:05 A.M., showed RN A left the computer screen open and unattended Resident #7 medication information visible in Hallway A. Observation showed residents and staff walked by the cart.
During an interview on 02/24/25 at 12:57 P.M., RN A said he/she knows he/she should close the screen when he/she walks away. He/She said it is a risk for HIPAA and it exposes resident information. He/She said he/she just forgets to minimize it.
3. Observation on 02/25/25 at 12:05 P.M., showed RN Bleft the computer screen open and unattended with Resident #61 medication information visible on the insulin cart. Observation showed residents and staff walked by the cart.
Observation on 02/25/25 at 12:08 P.M., showed RN B left the computer screen open and unattended with Resident #74 medication information visible on the insulin cart. Observation showed residents and staff walked by the cart.
During an interview on 02/25/25 at 2:13 P.M., RN B said he/she should not leave computer screen open exposing resident information when he/she walks away from cart. He/She said it is a risk of privacy and HIPAA.
4. Observation on 02/27/25 at 07:45 A.M., showed RN C left the computer screen open and unattended with Resident #26 medication information visible in the dining room. Observation showed residents and staff walked by the cart.
Observation on 02/27/25 at 07:50 A.M., showed RN C left the computer screen open and unattended with Resident #7 medication information visible in the dining room. Observation showed residents and staff walked by the cart.
Observation on 02/27/25 at 08:00 A.M., showed RN C left the computer screen open and unattended with Resident #79 medication information visible in the dining room. Observation showed residents and staff walked by the cart.
During an interview on 02/27/25 at 8:24 A.M., RN C said he/she should have closed her screen when he/she walked away from the cart. He/She said it is a risk of HIPAA and exposing resident information.
During an interview on 02/27/25 at 4:49 P.M., Director of Nursing (DON) said computer screens should not be up with resident information showing. He/She said the risk of leaving computer screen up is anyone going by computer can see the resident information on the screen. He/She said the staff with that computer is responsible for ensuring the residents information is not exposed when they walk away.
During an interview on 02/27/25 at 5:46 P.M., the administrator said when staff walk away from their computer, the screen should be minimized because of privacy and HIPAA. He/She said when he/she seeing a screen open he/she will close them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to document an accurate Minimum Data Set (MDS), a federally mandated...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to document an accurate Minimum Data Set (MDS), a federally mandated assessment, when staff did not accurately code section A of the MDS for two residents (Residents #9 and #41), and section B of the MDS for one resident (Resident #43) out of 18 sampled residents. The facility's census was 75.
1. Review of the facility's policies showed staff did not provide a MDS policy.
2. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, a guideline for staff to complete each resident's MDS, dated [DATE], showed federal regulations require the assessment accurately reflects the resident's status, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations.
3. Review of Resident #9's Annual MDS, dated [DATE], showed staff assessed the resident as follows:
-re-admitted to facility 06/05/23;
-Moderate cognitive impairment;
-Has not been evaluated by Level II Pre-admission Screen and Resident Review (PASRR) and determined to have a serious mental illness and/or mental retardation or a related condition;
-Diagnosis of Manic Depression.
Review of the resident's PASARR Level II determination, dated 02/07/23, showed the resident evaluated with a PASRR related disability: specifically, Serious Mental Illness related to diagnosis of Bipolar I Disorder.
During an interview on 02/27/25 at 1:05 P.M., the MDS Coordinator said based on the RAI instructions, section A1500 and A1510 on the resident's MDS were inaccurate and was just an oversight by him/her. He/She said he/she had never seen a copy of the resident's PASARR Level II determination report prior.
During an interview on 02/27/25 at 4:45 P.M., the Director of Nursing (DON) said Section A1500 and A1510 on the resident's MDS were inaccurate.
4. Review of Resident #41's Annual MDS, dated [DATE], showed staff assessed the resident as follows:
-admitted to facility 11/17/23;
-Cognitively intact;
-Has not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition;
-Diagnoses of Major Depression Disorder and Post Traumatic Stress Disorder (PTSD).
Review of the resident's PASRR Level II determination, dated 02/27/24, showed the resident evaluated with a PASRR related disability: specifically, Serious Mental Illness.
During an interview on 02/27/25 at 4:00 P.M., the MDS Coordinator said he/she was not aware resident was a level two. He/She said the resident's MDS should reflect the resident's level two.
5. Review of Resident #43's annual MDS, dated [DATE], showed staff assessed the resident as follows:
-admitted to facility 03/29/22;
-Cognitivley intact;
-Adequate vision.
During an interview on 02/24/25 at 7:46 A.M., the resident said he/she can't see and is blind. The resident said, I can see only outlines and some shapes. The resident said he/she can not watch TV, because he/she is not able to see it.
During an interview on 02/27/25 at 4:45 P.M., the DON said the resident's vision assessment of adequate vision is inaccurate on his/her MDS, the resident is visually impaired.
6. During an interview on 02/27/25 at 9:55 A.M., the DON said the MDS Coordinator had been in his/her role for about seven months and is responsible to accurately complete residents' MDS assessments. He/She said no one double checks the accuracy of the MDS assessments, but as the DON he/she is responsible for the oversight. The facility does not have a Policy for MDS. He/She said facility staff uses the CMS guidelines and the RAI manual as guidance to complete each resident's MDS.
During an interview on 02/27/25 at 1:05 P.M., the MDS Coordinator said he/she was responsible to accurately complete each resident's MDS, and uses the CMS guidelines and the RAI manual to complete the MDSs. He/She said all sections including Section A and B of the MDS should accurately reflect each resident at the time of the assessment.
During an interview on 02/27/25 at 5:48 P.M., the administrator said he/she expects each resident's MDS to be accurately completed per CMS guidelines. He/She said the DON oversees the MDS Coordinator.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to meet professional standards of care when staff did not document ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to meet professional standards of care when staff did not document an order for code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) for one Resident #9, did not document a clear order for code status for one Resident #37, and did not document clinical condition or symptoms for use of medications for three Residents (#75, #79, and #80) out of 18 sampled residents. The facility's census was 75.
1. Review of the facility's policy titled, Code Status/Advance Directives Procedure, dated [DATE], showed:
-Nursing will discuss with the patient, if unable-the legal/patient representative about code status Do not Resuscitate (DNR) versus cardiopulmonary resuscitation (CPR) as well as other life sustaining measures on the Physician's Orders for Life Sustaining Treatment (POLST) Form;
-The POLST Form is completed by Nursing and forwarded to Health Information Department for physician signature;
-Code status documentation by nurse: Enter order for DNR versus CPR;
-Audit Process: Health Information Department will audit all new admissions by verifying the order, banner icon, and POLST Form (if in place all match). Health Information Department will continue to audit on a monthly basis by running the Advance Directives Report and comparing to ensure Resident Banner, order and POLST form (if used) all match.
2. Review of Resident #9's annual Minimum Date Set (MDS), a federally mandated assessment, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, and re-admitted to facility on [DATE].
Review of the resident's Physician's Order Sheet (POS), dated [DATE] through [DATE], showed the POS did not contain documentation of an order for code status.
During an interview on [DATE] at 10:28 A.M., the Director of Nursing (DON) said each resident should have an order for code status to indicate either full code (CPR) or DNR. He/She said the admitting nurse is responsible to verify the code status and enter the order, and the health information staff audits after.
During an interview on [DATE] at 1:43 P.M., the resident said he/she is a full code and would like staff to perform CPR if needed.
During an interview on [DATE] at 1:32 P.M., the Clinical Coordinator said the resident did not have an order for code status and should have one on his/her POS.
During an interview on [DATE] at 4:28 P.M., the Health Information staff said he/she was not sure why the resident did not have an order for CPR or DNR since [DATE], when the order was apparently discontinued and did not get re-entered. He/She said he/she completes quarterly audits, but does not necessarily check for code status orders on residents who have been at the facility for a while.
3. Review of Resident #37's admission MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and admitted on [DATE].
Review of the resident's POS, dated [DATE] showed an order for a DNR code status.
Review of the resident's POS, dated [DATE] showed an order for a Full Code status.
During an interview on [DATE] at 4:48 P.M., the DON said the resident should not have two different orders for his/her code status and did not know why he/she did. He/She said the admitting nurse is responsible to verify the code status and enter the order, and the health information staff audits after.
4. During an interview on [DATE] at 1:32 P.M., the Clinical Coordinator said each resident should have an order for either DNR or CPR, and the admitting nurse is responsible to verify the code status and enter the order. He/She said the health information staff is responsible to check orders a few days after admission and ensure each resident has an order for CPR or DNR and if not, notify the nurse for follow up.
During an interview on [DATE] at 4:28 P.M., the health information staff said the nurse is responsible to document the order for code status on admission, he/she audits the medical records a few days after and notifies the nurse of any discrepancy or missing orders.
During an interview on [DATE] at 5:48 P.M., the administrator said each resident should have a physician's order for code status to indicate either DNR or CPR. He/She said the nursing staff is responsible to ensure there is an order and the health informatiom department monitors.
5. Review of the facility's policy titled, Medication and Treatment Orders, dated [DATE], showed orders for medications and treatments will be consistent with principles of safe and effective order writing. Orders for medications must include a clinical condition or symptoms for which the medication is prescribed.
6. Review of Resident #75's Entry Tracking MDS, dated [DATE], showed the resident admitted to the facility on [DATE].
Review of the resident's POS, dated [DATE] to [DATE], showed an order for Cefdinir (antibiotic) capsule 300 milligrams (mg), one capsule by mouth twice daily for ten days. Review showed the POS did not contain documentation of a clinical condition or symptoms for the Cefdinir medication.
During an interview on [DATE] at 10:53 A.M., the Infection Preventionist/Clinical Coordinator said the resident recently admitted with antibiotic treatment for a urinary tract infection. He/She said on weekends, the admitting nurse is responsible to ensure an antibiotic medication has an indication for use, and he/she is responsible on weekdays, but had not had a chance to review the resident's medications yet.
7. Review of Resident #79's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-admitted to facility [DATE];
-Diagnoses of seizure isorder or epilepsy, Schizophrenia (a chronic mental illness that affects how people think, feel and behave);
-Received antipsychotic medication with indication noted.
Review of the Resident's POS, dated [DATE] through [DATE], showed an order for Aripiprazole (an antipsychotic medication used to treat schizophrenia) 30 mg tablet, one tablet by mouth daily at 10:30 A.M. Review showed the POS did not contain documentation of a clinical condition or symptoms for the Aripiprazole medication.
8. Review of Resident #80's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-admitted to facility [DATE];
-Diagnoses: Hypo-osmolality and hyponatremia (excess water in the body with low sodium levels in the blood), high blood pressure.
Review of the Resident's POS, dated [DATE] through [DATE], showed the physician ordered Amlodipine (used to treat high blood pressure) 5 mg tablet, one tablet by mouth daily at 10:30 A.M. Review of the POS showed it did not contain documentation of a clinical condition or symptoms for the Amlodipine medication.
9. During an interview on [DATE] at 11:00 A.M., the Infection Preventionist/Clinical Coordinator said he/she said the facility recently started using an external company to enter admission orders for residents and the process has not being going smoothly, but he/she expects the admitting nurse to verify all residents' admission orders have an indication for use within the first four hours of admission and notify him/her or the DON for follow-up.
During an interview on [DATE] at 1:26 P.M., the MDS Coordinator said residents' medications should have an indication for use and he/she had not seen that on all medication orders at the facility, so he/she was not sure if it was required by facility staff.
During an interview on [DATE] at 1:32 P.M., the Infection Preventionist/Clinical Coordinator said all medications listed on the residents' POS should have an indication for use regardless of the type of medication. He/She said he/she is responsible to ensure as needed medications and antibiotics have an indication for use, and the DON oversees all other medications.
During an interview on [DATE] at 4:48 P.M., the DON said each prescribed medication listed on residents' POS should have an indication for use regardless of the type of medication. He/She said Resident #79 and #80 admitted to the facility almost two weeks prior and all their medications should have an indication for use. He/She said the pharmacist also reviews the medications for new admissions and give recommendations for medications without an indication for use. He/She said he/she is responsible to oversee but he/she is currently behind.
During an interview on [DATE] at 5:17 P.M., Licensed Pharmacist G said he/she tries to review the medications for residents newly admitted within one week and can complete the medication reviews remotely. He/She said he/she had not reviewed the medications for residents admitted after his/her last visit to facility on or about [DATE] and planned to complete those reviews the next day when he/she is at the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to obtain consents for side rails and failed to comple...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to obtain consents for side rails and failed to complete side rail assessments for five residents (Resident #18, #43, #64, #76 and #77), out of seven sampled residents. The facility census was 75.
1. Review of the facility's Proper use of Side Rails Policy, 12/2016, showed:
-An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails;
-When used for mobility or transfer, an assessment will include a review of the resident's:
-Bed mobility;
-Ability to change positions, transfer to and from bed or chair, and stand and toilet;
-Risk of entrapment from the use of side rails;
-That the beds dimensions are appropriate for the resident's size and weight.
-Consent for using restrictive deices will be obtained from the resident or legal representative per facility protocol;
-Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks.
2. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/08/25, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Impairment to one side of lower extremity (hip, knee ankle, foot);
-Required substantial/max assist from staff to roll left and right, sitting to lying in bed, lying to sitting on side of bed.
Review of the resident's electronic medical record (EMR), showed the record did not contain a signed consent from the resident or resident representative for the use of bed rails, or a side rail assessment.
Observation on 02/24/25 at 12:16 P.M., showed the resident in bed with bed rails to both sides in the upright position.
Observation on 02/25/25 at 9:36 A.M., showed the resident in bed with bed rails to both sides in the upright position.
Observation on 02/26/25 at 8:42 A.M., showed the resident in bed with bed rails to both sides in the upright position.
During an interview on 02/27/25 at 1:26 P.M., the MDS/Care Plan Coordinator said the resident uses bed bed rails and he/she recently did an audit for residents with bed rails but must have missed the resident.
3. Review of Resident #43's annual MDS, dated [DATE], showed:
-Cognitively intact;
-No impairment;
-Not assessed for assist from staff to roll left and right, sitting to lying in bed, lying to sitting on side of bed.
Review of the resident's EMR showed the record did not contain an signed consent from the resident or resident representative for the use of bed rails, or a side rail assessment.
Observation on 02/24/25 at 8:45 A.M., showed the resident in bed with bed rail on left side in the upright position.
Observation on 02/25/25 at 11:30 A.M., showed the resident in bed with bed rail on left side in the upright position.
Observation on 02/26/25 at 3:00 P.M., showed the resident in bed with bed rail on left side in the upright position.
Observation on 02/27/25 at 5:15 P.M., showed the resident in bed with bed rail on left side in the upright position.
4. Review of Resident #64's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Impairment both sides upper and lower extremities;
-Dependent with chair/bed-to-chair transfers;
-Substantial/maximal assist with rolling left and right.
Review of the resident's EMR showed the record did not contain an signed consent from the resident or resident representative for the use of bed rails or a side rail assessment.
Observation on 2/24/25 at 10:21 A.M., showed the resident in bed with both side rails in the upright position.
Observation on 2/25/25 at 11:02 A.M., showed the resident in bed with both side rails in the upright position.
Observation on 2/27/25 at 10:15 A.M., showed the resident in bed with both side rails in the upright position.
5. Review of Resident #76's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Impairment both sides lower extremity;
-Substantial/maximal assist with rolling left and right and chair/bed-to-chair transfers;
-Partial/moderate assist with lying to sitting on side of bed.
Review of the resident's EMR showed the record did not contain an signed consent from the resident or resident representative for the use of bed rails or a side rail assessment.
Observation on 2/24/25 at 9:34 A.M., showed the resident in bed with both side rails in the upright position.
During an interview on 02/27/25 at 10:20 A.M., the resident said he/she uses the side rails to help him/her sit up in bed and to help turn over while in bed.
6. Review of Resident #77's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Impairment both sides lower extremity;
-Dependent on staff for assistance to roll left and right, sitting to lying in bed, lying to sitting on side of bed.
Review of the resident's EMR, showed the record did not contain an signed consent from the resident or resident representative for the use of bed rails, or a side rail assessment.
Observation on 02/24/25 at 10:49 A.M., showed the resident in bed with both side rails in the upright position.
Observation on 02/26/25 at 9:30 A.M., showed the resident in bed with both side rails in the upright position.
Observation on 02/27/25 at 1:50 P.M., showed the resident in bed with both side rails in the upright position.
7. During an interview on 02/27/25 at 1:26 P.M., the MDS/Care Plan Coordinator said he/she was not sure who was responsible to complete the residents' initial side rail assessments and obtain informed consents, he/she is only responsible to complete the quarterly side rail assessments with informed consent.
During an interview on 02/27/25 at 2:05 P.M., Registered Nurse (RN) D said upon admission the resident or resident's family can request side rails. He/She said an evaluation would be completed to ensure resident can use the side rails. He/She said the admitting nurse would do the bed rail assessment in the observations tab and at that time go over the risks of entrapment with the resident or family and ensure they consent to use of side rails. He/She said from there he/she informs the Director of Nursing (DON) that side rails are wanted. He/She said he/she is unsure who does the bed rail assessments after the admission assessment is completed or how often they are done.
During an interview on 02/27/25 at 9:44 A.M., the DON said the MDS Coordinator should be doing the bed rail assessment quarterly. He/She said the consents are at the bottom of the bed rail utilization assessment. He/She said upon admission the charge nurse should complete the bed rail assessment, but sometimes it may be the next day after therapy has evaluated the resident and determined bed rails are needed. He/She said all residents should have a consent for bed rails upon determination of need. He/She said it is the charge nurse responsibility for obtaining consent and the MDS Coordinator should be double checking when he/she is doing the quarterly assessments and updating the MDS. He/She said no one is currently overseeing if the MDS Coordinator is checking for the bed rail assessments. He/She said it should be the DONs responsibility to check and ensure consents and bed rail assessments are being done.
During an interview on 02/27/25 at 5:43 P.M., the administrator he/she is unsure who does the bed rail assessments or how often they should be done. He/She said there should be consents for all residents who use bed rails. He/She said charge nurses ensure consents are done and the DON should oversee that they are being obtained.
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, facility staff failed to provide a barrier for the glucometer (a device for ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide a barrier for the glucometer (a device for monitoring blood sugars) supplies for seven residents (Resident #7, #26, #52, #55, #61, #74, and #79) out of seven sampled residents. Facility staff failed to wear gloves while administering insulin to three residents (Resident #52, #61, and #74) out of seven sampled residents. Facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness).The facility census was 75.
1. Review of the facility's policy titled, Cleaning and Disinfecting Blood Glucose Meters, dated 2019, showed facility staff were directed to apply gloves before performing a blood glucose test, glucose monitoring, administration of insulin, and any other procedure that involved potential exposure to blood or body fluids.
2. Review of Resident #7's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 02/27/25 at 7:50 A.M., showed Registered Nurse (RN) C obtained a blood sample and placed the glucometer directly on the dining room table without a barrier.
3. Review of Resident #26's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 02/27/24 at 7:45 A.M., showed RN C obtained a blood sample and placed the glucometer directly on the dining room table without a barrier.
4. Review of Resident #52's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 02/25/25 at 12:02 P.M., showed RN B obtained a blood sample and placed the glucometer directly on the dining room table without a barrier.
Observation on 02/25/25 at 12:03 P.M., showed RN B did not wear gloves when he/she administered insulin to resident.
5. Review of Resident #55's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 02/27/25 at 8:10 A.M., showed RN C obtained a blood sample and placed the glucometer directly on the dining room table without a barrier.
6. Review of Resident #61's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 02/25/25 at 12:05 P.M., showed RN B obtained a blood sample and placed the glucometer directly on the dining room table without a barrier.
Observation on 02/25/25 at 12:06 P.M., showed RN B did not to wear gloves when he/she adminstered insulin to resident.
7. Review of Resident #74's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 02/25/25 at 12:10 P.M., showed RN B obtained a blood sample and placed the glucometer directly on the dining room table without a barrier.
Observation on 02/25/25 at 12:11 P.M., showed RN B did not to wear gloves when he/she administered insulin to resident.
8. Review of Resident #79's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 02/27/25 at 8:00 A.M., showed RN C obtained a blood sample and placed the glucometer directly on the dining room table without a barrier.
9. During an interview on 02/25/25 at 2:13 P.M., RN B said he/she should have not put the glucose meter on the table due to contamination. He/She said he/she should wear gloves when having the potential for coming in contact with bodily fluids. He/She said when administering insulin, you could have the potential for coming in contact with bodily fluids. He/She said he/she does not have an explanation why he/she didn't wear gloves while administering insulin.
During an interview on 02/27/25 at 08:24 A.M., RN C said he/she does not see a problem with putting the glucose meter on the table after obtaining a blood sample. He/She agreed it could be a risk for blood splitter where residents are eating and risk for contamination.
During an interview on 02/27/25 at 4:30 P.M., the Director of Nursing (DON) said nurses should wear gloves when administering insulin. He/She said not wearing gloves is a risk of exposure to blood. He/She said staff should probably not lay the glucose meter on the dining room table because there could be a chance another resident could get ahold of the meter with blood still on the glucose strip. He/She said or if the nurse gets blood on glove and then touches the glucose meter and sets the meter on the table there is a chance of blood contamination.
During an interview on 02/27/25 at 5:46 P.M., the administrator said it is probably not best practice to lay the glucose meter on the dining table due to potential of cross contamination. He/She said he/she is not sure if gloves should be worn while administering insulin.
10. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed:
The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.
Facilities must have water management plans and documentation that, at a minimum, ensure each facility:
-Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;
-Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit;
-Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
Review of the facility's Water Quality Management Program, dated November 2023 showed procedures included:
-Implement a water management program that considers the ASHREA (American Society of Heating, Refrigerating and Air-Conditioning Engineers) standards and the CDC (Centers for Disease Control and Prevention) toolkit that includes control measures such as physical controls, temperature management, checking disinfectant levels, visual inspections and environmental testing for pathogens;
-Document the results of the testing and corrective actions taken when water control limits are not met.
Review of the facility's EPP policy showed control measures included:
-Visual inspection and checking disinfectant levels at the water main entering the facility;
-Visual inspection of ice machines;
-Checking disinfectant levels at sinks/showers;
-Checking temperatures at water heaters, all sinks and showers and the kitchen.
Review of the facility's EPP showed the control measures did not indicate normal ranges or frequencies.
Review of the program control measures and corrective actions process flow diagram indicated staff were to document all results of routine control measure monitoring and corrective actions where applicable.
Review of the Legionella Water Management Plan Review task from the facility's computerized preventative maintenance program (TELS), marked done on time May 1, 2024, showed instructions for staff to:
-Identify how often routine monitoring and testing are completed;
-Decide where control measures should be applied and how to monitor them. Staff will need to monitor and measure if preventative measures are working;
-Establish ways to intervene when control limits are not met;
-Document and communicate all activities.
Review of the facility's Water Quality Management Program records, showed the records did not contain:
-Acceptable ranges for control measures;
-Corrective actions to take if control measures are outside acceptable range;
-Documentation of routine monitoring of control measures.
During an interview on 02/26/25 at 9:50 A.M., the maintenance director said he/she was not familiar with control measures in the water quality management program. The maintenance director said he/she had never looked at the facility specific risk assessment in the water plan. The maintenance director said he/she used a swimming pool test strip to test water quality. The maintenance director said he/she followed the normal ranges listed on the bottle but he/she did not document results and never took any action based on results.
During an interview on 02/26/25 at 3:35 P.M., the administrator said he/she and maintenance staff were responsible for implementing the water quality management program. The administrator said he/she had reviewed the plan but was not very knowledgeable of the contents. The administrator said he/she was not aware of any specific inspections or action the maintenance director performed as part of the water management program. The administrator said specific control measure ranges and corrective actions should be included in the water management plan but he/she could not locate them.
MINOR
(B)
Minor Issue - procedural, no safety impact
ADL Care
(Tag F0677)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide care to meet basic hygiene needs for three ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide care to meet basic hygiene needs for three (Resident #5, #24, and #80) out of five sampled residents. The facility census was 75.
1. Review of the facility's policies showed the staff did not provide a bath policy.
2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/30/25, showed staff assessed the resident as follows:
-Brief Interview for Mental Status ((BIMS) - a short cognitive screening tool) score not conducted as the resident is rarely/never understood;
-Did not reject care;
-Required substantial/max assist from staff with personal hygiene and to shower/bathe.
Review of the resident's care plan, dated 02/12/25, showed staff are directed to assist the resident with dressing, personal hygiene, transfers, and showers.
Review of the facility's shower schedule showed the resident will be assisted with a bed bath/shower on Tuesdays and Fridays by facility staff.
Review of the resident's electronic record for bathing, dated 12/01/24 through 02/27/25, showed staff documented showers were provided on 12/04/24, 12/11/24, 12/17/24, 12/27/24, 01/07/25, 01/24/25, and 02/25/25. Staff did not document refusals.
Observation on 02/24/25 at 8:35 A.M., showed the resident in the dining room with greasy hair.
Observation on 02/25/25 at 9:23 A.M., showed the resident in bed with greasy hair.
During an interview on 02/27/25 at 4:36 P.M., the Clinical Coordinator said the resident does not refuse his/her showers.
3. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-BIMS not assessed;
-Did not reject care;
-Required substantial/max assist from staff with personal hygiene and to shower/bathe.
Review of the resident's care plan, dated 02/06/25, showed the resident needs substantial assist with showers, upper and lower body dressing and personal hygiene.
Review of the facility's shower schedule showed the resident will be assisted with a bed bath/shower on Mondays and Thursdays by facility staff.
Review of the resident's electronic record for bathing, dated 12/01/24 through 02/24/25, showed staff documented bed/showers provided on 12/05/24, 12/12/24, 12/26/24, 01/09/25, 01/15/25, 01/27/25, 02/03/25, 02/12/25, and 02/13/25.
Observation on 02/24/25 at 2:00 P.M., showed the resident in bed with long nails with a dark substance underneath and greasy hair.
Observation on 02/26/25 at 10:30 A.M., showed the resident in bed with long nails with a dark substance underneath and greasy hair.
During an interview on 02/24/25 at 2:01 P.M., the resident said he/she does not get showers very often.
During an interview on 02/27/25 at 1:47 P.M., the resident said it makes him/her mad when he/she does not get a shower, because he/she was told they are to get a shower twice a week when he/she came to the facility.
During an interview on 02/27/25 at 4:36 P.M., the Clinical Coordinator said the resident occasionally refuses his/her showers, but he/she was not sure if there was a pattern.
4. Review of Resident #80's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-admitted to facility 02/14/25;
-Severely cognitively impaired;
-Did not reject care;
-Required supervision with oral hygiene, personal hygiene;
-Ability to shower/bathe self: not attempted due to medical or safety concerns.
Review of the resident's care plan, dated 02/20/25, showed staff are directed to assist the resident with some or all ADLs, and help him/her keep dentures clean after meals and at bedtime.
Review of the facility's shower schedule showed the resident will be assisted with a bed bath/shower on Tuesdays and Fridays by facility staff.
Review of the resident's electronic records for bathing, dated 02/14/25 through 02/27/25, showed staff documented one shower was provided on 02/25/25 and one refusal on 02/18/25.
Observation on 02/24/25 at 10:07 A.M., showed the resident ambulated with a walker and staff assist down the hallway to his/her room. His/Her hair appeared uncombed and disheveled.
Observation on 02/25/25 at 12:17 P.M., showed the resident sat at the dining table in his/her robe, and his/her hair appeared uncombed and disheveled.
During an interview on 02/24/25 at 10:19 A.M., the resident said he/she admitted to facility over a week prior and had some oral concerns regarding his/her lower gum and dentures he/she needed staff to help resolve, as well as not being offered a shower yet.
During an interview on 02/25/25 at 12:18 P.M., the resident said he/she was still waiting for staff to assist him/her with a shower so he/she could feel refreshed.
During an interview on 02/27/25 at 4:36 P.M., the Clinical Coordinator said the resident could refuse his/her showers, but he/she was not aware/notified the resident refused any showers since his/her admission.
5. During an interview on 02/27/25 at 4:22 P.M., Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) F said the shower aide was already gone for the day. He/She said Resident #5 and #80 is scheduled to receive a shower on Tuesdays and Fridays, and Resident #24 is scheduled on Mondays and Thursdays. He/She said the shower aide documents when he/she assists a resident with a shower in the electronic record.
During an interview on 02/27/25 at 4:29 P.M., Registered Nurse (RN) C said Resident #5 and #80 is scheduled to receive a shower on Tuesdays and Fridays, and Resident #24 is scheduled on Mondays and Thursdays. The RN said the shower aide documents when he/she assists a resident with a bath/shower in the electronic record, and if the resident refuses. He/She said the shower aide does not always notify the nurse of a refusal, and does not normally document resident refusals on paper.
During an interview on 02/27/25 at 4:36 P.M., the Clinical Coordinator said the shower aide is expected to document when he/she assists a resident with a bath/shower in the electronic record, and if the resident refuses once or twice. He/She said if a resident develops a pattern of refusing, then the shower aide is expected to notify the charge nurse and complete a paper shower sheet and have the resident sign his/her refusal, then the nurse or the clinical coordinator would follow-up with the resident.
During an interview on 02/27/25 at 4:38 P.M., the Director of Nursing (DON) said the facility has two shower aides who are expected to offer the residents a bath or shower twice per week, and if the resident refuses, the shower aide should document the refusal in the electronic record and notify the charge nurse of the refusal.
During an interview on 02/27/25 at 5:48 P.M., the administrator said he/she expects staff to offer residents a bath or shower at least once per week and if a resident refuses, then staff should re-approach the resident and offer alternate options such as a different day or time. The administrator said he/she is not sure why showers are not being completed, because there are two shower aides on staff.
MO00249498
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0575
(Tag F0575)
Minor procedural issue · This affected most or all residents
Based on observation and interview, facility staff failed to post, in a form and manner accessible to residents, resident representative, visitors and staff the required telephone number to the Depart...
Read full inspector narrative →
Based on observation and interview, facility staff failed to post, in a form and manner accessible to residents, resident representative, visitors and staff the required telephone number to the Department of Health and Senior Services (DHSS) elder abuse and neglect hotline. The census was 75.
1. Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, showed the names, addresses, and telephone numbers of all pertinent State client advocate groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network are available to all patients and their families and will be posted prominently in the center.
2. Observation of the facility on 02/24/25 at 1:00 P.M., showed the DHSS Abuse and Neglect Hotline number posted at the end of an unoccupied hall and not in a prominently located area within the facility for residents to see.
Observation of the facility on 02/25/25 at 8:15 A.M., showed the DHSS Abuse and Neglect Hotline number posted at the end of an unoccupied hall and not in a prominently located area within the facility for resident to see.
Observation of the facility on 02/26/25 at 10:15 A.M., showed the DHSS Abuse and Neglect Hotline number posted at the end of an unoccupied hall and not in a prominently located area within the facility for residents to see.
Observation of the facility on 02/27/25 at 2:25 P.M., showed the DHSS Abuse and Neglect Hotline number posted at the end of an unoccupied hall and not in a prominently located area within the facility for residents to see.
During an interview on 02/27/25 at 2:41 P.M., the Social Service Designee (SSD) said the hotline number was posted up front in the facility, however when he/she went to look he/she realized it was not there. He/She said they are unsure why its not posted any longer.
Observation on 02/27/25 at 2:45 P.M., showed the front area of the facility did not contain the DHSS Abuse and Neglect Hotline number posted.
During an interview on 02/27/25 at 4:45 P.M., the Director of Nursing (DON) said the hotline number is posted back by his/her office and thought it was posted in the front of the building. The DON said he/she was not aware the number wasn't posted up front. The DON said it is not in a good location, it should be posted visible for everyone to see it.
Observation on 02/27/25 at 5:00 P.M., showed the front area of the facility did not contain the DHSS Abuse and Neglect Hotline number posted.
During an interview on 02/27/25 at 5:05 P.M., Resident #42 said he/she has never heard anyone talk about the hotline number. He/She said she does not know where the number is located.
During an interview on 02/27/25 at 5:07P.M., Resident #76 said he/she does not know where the hotline number is posted. The resident said he/she has not seen this posted around anywhere.
During an interview on 02/27/25 at 5:50 P.M., the Administrator said the SSD is responsible making sure the information is posted. The administrator said the information use to be posted in the front, but it is back by the DON's office.
May 2024
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
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which res...
Read full inspector narrative →
Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 being transported to the hospital after an adverse reaction. The facility census was 76.
The administrator was notified on 5/6/24 of past Non-Compliance, which occurred on 4/21/24 when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 4/23/2024.
1. Review of the facility Medication Administration policy, dated 1/1/2019, showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications should do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Before administration of medication, the nurse should assure he/she administered to the correct patient.
2. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/27/24, showed staff assessed the resident:
-Moderately cognitive impaired;
-Diagnoses of Anemia, Gastric reflux disease, Benign prostatic hyperplasia (Age-associated prostate gland enlargement that can cause urination difficulty), and anxiety.
Review of the resident's plan of care, 2/29/24, showed staff are directed to give medications as ordered.
Review of the resident's progress notes, dated 4/20/24 at 11:03 P.M., showed Licensed Practical Nurse (LPN) A documented at 9:10 P.M., this agency nurse entered resident's room and addressed the resident by the name of the roommate and the resident greeted the nurse in what the nurse assumed to be the correct resident. Nurse then proceeded to administer what was thought to be the correct bedtimes medications which were 22 units of Lantus insulin (treats diabetes), 25 milligrams (mg), hydralazine (treats high blood pressure), 1000 mg of metformin (treats diabetes), 300 mg of gabapentin (treats nerve pain).When nurse went back to check foley catheter resident didn't have one and that is when the acknowledgment of medication error had occurred. Nurse then asked the certified nursing assistance (CNA) to get the second nurse. Agency nurse then asked the second aide to take vital signs every 15 minutes and to begin to help him/her eat some sweet foods from the snack cart. He/she ate pudding and another dessert. Second nurse then assisted agency nurse and called the doctor to inform him/her of medication error. The physician prescribed blood sugar checks every 30 minutes because the resident was given insulin and is not a diabetic and does not have blood pressure issues until the next shift and if the blood sugar drops below 100 then send out to the hospital.
Review of the resident's hospital records, dated 4/20/24, showed the resident admitted to the hospital due to his blood sugar dropping down to 70 and his blood pressure trending down after his/her skilled nursing facility staff administered the wrong medications.
Review of the investigation, dated 4/20/24, showed LPN A adminsitered another resident's medication to Resident #1 because Resident #1 acknowledged staff when he/she said his/her name. LPN A was unfamilair with residents. The residents blood sugar stayed low the resident was sent to emergency room and admitted . Review showed nursing staff in-serviced on proper medication administration on 04/23/24.
During an interview on 5/6/24 at 9:14 A.M., the resident said he/she got medications that was his/her roommates and had to spend two days in the hospital because he/she does not have blood pressure issues normally and is not a diabetic.
During an interview on 5/6/24 at 10:18 A.M., the administrator said there was a full investigation into a medication error with the resident. The agency nurse gave the resident the wrong medication. The physician was contacted immediately as were the family, vitals checks started, snacks and reverse medications given and the resident was then sent out to the hospital for monitoring.
During an interview on 5/21/24 at 11:11 A.M., LPN A said he/she entered the room and addressed the resident and he/she responded, he/she was not aware the resident had a hearing deficit. He/She administered the medication and then went to change the resident catheter and he/she did not have one and this is when the error was noticed. The physician was immediately notified and snacks were given, the physician gave new orders to check blood sugar but the resident started having adverse reactions so he/she was immediately sent to the hospital.
During an interview on 5/21/24 at 11:20 the Director of Nursing (DON) said he/she was contacted by the nurses on shift that a major medication error had occurred. LPN A had given the resident his/her roomates medication. He/She had addressed the resident and the resident had responded and the medication was administered. He/She said the review of the MAR showed it flipped the A and B bed as well. He/She said the physician and family was contacted immediately, vital signs were ordered, and the resident was given snacks. The resident was sent out to the hospital shortly after when he/she started having adverse reactions.
MO00235022
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for it's residents competen...
Read full inspector narrative →
Based on interview and record review, the facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for it's residents competently during both day-to-day operations and emergencies as required. The facility census was 73.
1. Review of the facility's Facility Assessment Report, dated September 2022 through August 2023, showed the assessment did not contain information on staffing for day-to-day operations and emergencies as required.
During an interview on 5/6/24 at 1:14 P.M., the administrator said he/she did not have a full facility assessment completed and is aware it is required to be done annually. He/She said he/she staffs by census.
MO00235022
MO00235450
Dec 2023
5 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 interviews and record review, facility staff failed to report a missing gift card for one resident (Resident #45) to the Department of Health and Senior Services (DHSS) within the required ti...
Read full inspector narrative →
Based on interviews and record review, facility staff failed to report a missing gift card for one resident (Resident #45) to the Department of Health and Senior Services (DHSS) within the required time frame. The facility census was 71.
1. Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/23, showed abuse, neglect, misappropriation of patient property and exploitation will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors or any other individual in this center. Review showed:
-The patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation;
-Any partner (staff) having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property, or exploitation must report the event immediately, but not later than two hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do no result in abuse or serious bodily injury;
-It is the policy of this facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are report per Federal and State Law;
-The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law.
Review of the facility's Customer Satisfaction, Service Recovery Defined Policy, revised June 2006, showed:
-Service recovery is a set of actions taken to resolve a customer concern;
-Any partner (staff) can recover a break down in service or a perceived break down in service;
-All partners (staff) will make it right on the spot when the following occurs:
-Lost or misplaced items/belongings;
-Broken or damaged personal items/belongings;
-Customer certificates are available for all partners to provide financial reimbursement choice up to $100.00 on the spot, they are to be completed and given to the Social Service Director (SSD) who will recover what they need through a team effort;
-Specialized Service Recovery may involve dollar amounts over the $100.00 limit set, and may require a more specialized approach;
-The Department Head in charge of Specialized Service Recovery will complete service recovery case form, follow up one on one with the customer immediately and again in 12-48 hours of the reported concern, report findings to the center administrator, and give a copy of the form for Quality Assurance (QA) trending purposes.
2. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/23/23, showed staff assessed the resident as cognitively intact.
Review of the facility's investigation report, dated 11/06/23, showed the resident reported a $200.00 gift card missing. The resident reported he/she bought the gift card on 11/02/23, noticed the card missing on 11/04/23, and reported it to staff on 11/05/23. The investigation contained a dated receipt from a local store on 11/02/23 which showed the resident had purchased a $200.00 gift card. The investigation showed the Social Service Director (SSD) followed up on 11/06/23, 11/07/23, and 11/08/23 with the local store. The facility investigation did not contain documentation followed up with the outcome of the investigation. The investigation did not contain documentation staff reported the incident to the State survey and certification agency.
During an interview on 12/11/23 at 11:50 A.M., the resident said he/she had a gift card in the amount of $200.00 come up missing a few days after he/she purchased it. The resident said he/she told staff when he/she noticed it was gone, but could not remember who he/she told first.
During an interview on 12/12/23 at 9:42 A.M., the SSD said on 11/06/23 he/she had a note on his/her office door stating the resident needed to see him/her. The SSD spoke to the resident who reported a $200.00 gift card missing to him/her on 11/06/23. The SSD said he/she did an investigation and could not determine what happened to the gift card. He/She said the facility did not report the missing gift card to DHSS because it took quite a while to get the information and he/she was never able to determine if the gift card was stolen, lost, or given away by the resident.
During an interview on 12/13/23 at 1:58 P.M., the SSD said he/she is responsible to investigate any missing items such as a gift card. The SSD said he/she is the department head in charge of specialized service recovery in this facility. The SSD said he/she is responsible to inform the administrator if it needs to be reported to DHSS.
During an interview on 12/13/23 at 2:30 P.M., the administrator said he/she was aware the resident was missing a $200.00 gift card. The administrator said when a staff member reports a missing item the SSD is responsible for doing the investigation on items such as a gift card. The administrator said he/she is ultimately responsible to file reports with DHSS. The administrator said he/she did not file a self-report with DHSS regarding the resident's missing gift card because the resident and family were not upset about it missing and the facility planned to replace it.
During an interview on 12/14/23 at 9:11 A.M., the DON said he/she expects staff to report missing items. The DON said any grievances regarding money are investigated and handled by the SSD and he/she would report those to him/her. The DON said she was made aware of the resident's missing gift card but he/she did not do the investigation. The DON said any reports of misappropriation are handled by the SSD and administrator. He/She said the SSD or administrator should report these investigations within a two-hour window of finding out to DHSS. The DON said he/she is not sure why the missing gift card was not report to DHSS and the administrator is responsible for that.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, facility staff failed to ensure one resident (Resident #20) had a physician order for oxygen usage. The facility cenus was 71.
1. Review of the facil...
Read full inspector narrative →
Based on observation, record review and interview, facility staff failed to ensure one resident (Resident #20) had a physician order for oxygen usage. The facility cenus was 71.
1. Review of the facility's Oxygen for Patient Use policy, revised November 2022, showed the policy did not contain direction on orders required for oxygen therapy.
2. Review of Resident's #20's admission Minimum Data Set (MDS), a federally mandated assessment, dated 10/16/23, showed staff assessed the resident as follows:
-Cognitively intact;
-Oxygen therapy;
-Diagnoses of chronic lung disease, respiratory failure, anxiety, and heart failure.
Review of the resident's Physicians Order Sheet (POS), dated 12/01/23, showed the record did not contain an order for the use of oxygen.
Observation on 12/11/23 at 01:04 P.M., showed the resident with his/her oxygen on per a nasal cannula.
Observation on 12/12/23 at 08:24 A.M., showed the resident with his/her oxygen on per a nasal cannula.
During an interview on 12/13/23 at 2:56 P.M., the resident said he/she is to have oxygen administered all the time and has been using oxygen since his/her hospitalization.
During an interview on 12/14/23 at 08:48 A.M., Certified Nurse Assistant (CNA) E said the resident used supplemental oxygen at all times.
During an interview on 12/14/23 at 08:53 A.M., Licensed Practical Nurse (LPN) A said the resident used supplemental oxygen at all times. The resident should have physician orders for the use of oxygen. The LPN said if orders were missing, the nurse should obtain physician orders. LPN A said he/she was not aware the resident did not have an order for oxygen use.
During an interview on 12/14/23 at 9:08 A.M., the Director of Nursing (DON) said residents should have physician orders for the use of any respiratory care. If orders were missing, the nurse should obtain physician orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, facility staff failed to update three residents (Resident #20, #59, and #68) ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, facility staff failed to update three residents (Resident #20, #59, and #68) care plans to include the use of oxygen. The facility census was 71.
1. Review of the facility's policies showed staff did not provide a policy for care plans.
2. Review of Resident's #20's admission Minimum Data Set (MDS), a federally mandated assessment, dated 10/16/23, showed staff assessed the resident as follows:
-Cognitively intact;
-Oxygen therapy;
-BiPAP therapy (a device that helps with breathing which provides distinct air pressure levels for inhalation and exhalation);
-Diagnoses of chronic lung disease, respiratory failure, anxiety, and heart failure.
Review of the resident's care plan, dated 10/18/23, showed the care plan did not contain information for the resident use of his/her BiPAP or oxygen therapy.
Review of the resident's Physicians Order Sheet (POS), dated 12/01/23, showed staff are directed to apply the BiPAP at bedtime and remove in the morning.
Observation on 12/11/23 at 1:04 P.M., showed the resident with his/her oxygen on per a nasal cannula and the BiPAP machine on the bedside table.
Observation on 12/12/23 at 8:24 A.M., showed the resident with his/her oxygen on per a nasal cannula on and the BiPAP machine on the bedside table.
During an interview on 12/13/23 at 2:56 P.M., the resident said he/she is to have oxygen administered all the time and has been using oxygen since his/her hospitalization.
During an interview on 12/14/23 at 08:48 A.M., Certified Nurse Assistant (CNA) E said the resident used supplemental oxygen at all times.
During an interview on 12/14/23 at 08:53 A.M., Licensed Practical Nurse (LPN) A said the resident used supplemental oxygen at all times.
3. Review of Resident's #59's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Oxygen therapy;
-Diagnoses of chronic lung disease and heart failure.
Review of the resident's care plan, updated 10/10/23, showed the care plan did not contain information for the resident use of his/her oxygen therapy.
Review of the resident's POS, dated 12/01/23, showed staff were directed to titrate (to change levels of oxygen flow) oxygen to keep oxygen saturation (which measures the amount of oxygen carried in the blood) greater than 92% every shift.
Observation on 12/11/23 at 2:15 P.M., showed the resident oxygen on per a nasal cannula.
Observation on 12/12/23 at 10:11 A.M., showed the resident oxygen on per a nasal cannula
During an interview on 12/14/23 at 8:48 A.M., CNA E said the resident used supplemental oxygen at all times.
During an interview on 12/14/23 at 8:53 A.M., LPN A said the resident used supplemental oxygen at all times.
4. Review of Resident's #68's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-Mildly cognitively impaired;
-Diagnoses of anemia, heart failure, chronic lung disease, non-hip fracture.
Review of the resident's care plan, updated 9/20/23, showed the care plan did not contain information for the resident use of his/her oxygen therapy.
Review of the resident's POS, dated 12/01/23, showed staff were directed to titrate oxygen to keep oxygen saturation greater than 92%.
Observation on 12/11/23 at 11:59 A.M., showed the resident oxygen on per a nasal cannula.
Observation on 12/12/23 at 8:55 A.M., showed the resident oxygen on per a nasal cannula.
5. During an interview on 12/14/23 at 8:48 A.M., CNA E said the care plan should include any respiratory care.
During an interview on 12/14/23 at 8:53 A.M., LPN A said care plans should include all aspects of oxygen use and treatments.
During an interview on 12/14/23 at 9:08 A.M., the Director of Nursing (DON) said the care plan should include all aspects of respiratory care.
During an interview on 12/14/23 at 9:34 A.M., the administrator said he/she would expect the care plan to address oxygen use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain adequate infection control practices to preve...
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 adequate infection control practices to prevent the transmission of infection when staff failed to clean a suction machine for one resident (Resident #8), during perineal care and staff applied oxygen tubing directly from the floor on one resident (Resident #11). Staff failed to change and date respiratory tubing for three residents (Resident #15, #20, and #59). The facility census was 71.
1. Review of the facility's Suction Machine, Care and Use of policy, dated 2006, showed the suction machine bottle should be emptied, washed with soapy water and rinsed after each use.
2. Review of Resident #8's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/18/23 showed staff assessed the resident:
-Required artificial intake of greater than 51 percent (%) of fluid and calories;
-Feeding tube (tube placed in the stomach to administer nutrition and/or hydration);
-Required suctioning;
-Diagnosis of stroke.
Observation on 12/11/23 at 10:41 A.M., showed a suction machine on the resident's nightstand next to the bed that contained a yellow substance.
Observation on 12/12/23 at 08:14 A.M., showed a suction machine on the resident's nightstand next to the bed that contained a yellow substance.
Observation on 12/13/23 at 8:10 A.M., showed Licensed Practical Nurse (LPN) A administered the resident's medications through the feeding tube. A suction machine sat on the resident's nightstand next to the bed that contained a yellow substance.
During an interview on 12/13/23 at 08:15 A.M., LPN A said the resident has not used the suction machine for about a week and the machine should have been taken from the room. He/She did not know how often the suction machine should be cleaned or sanitized but the nurses are responsible to do it.
During an interview on 12/13/23 at 09:49 A.M., the Director of Nursing (DON) said he/she would need to see the suction machine and refer to the policy to know when it should have been cleansed.
During an interview on 12/13/23 at 01:25 P.M., the DON said the suction machine should have been cleaned by the nurses at least every seven days or as needed. He/She said after viewing the contents of the machine, it should have been cleaned by the nurses for infection control reasons.
During an interview on 12/14/23 at 9:12 A.M., the DON said hands should be washed between glove changes to prevent infection since the tube is a direct line to the stomach.
3. Review of the facility's Hand Hygiene policy, dated June 2023, showed hand hygiene includes both handwashing with either plain or antiseptic-containing soap and water, and use of alcohol-based products that do not require use of water. Review showed staff are to provide hand hygiene before and after removal of gloves and before and after contact with each patient.
Review of the facility's Oxygen for Patient Use policy, dated November 2022, showed the policy did not contain direction on oxygen tubing storage or handling.
4. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident:
-Required substantial and/or maximum assistance with toileting;
-Did not wear oxygen;
-Diagnosis of stroke.
Observation on 12/13/23 at 2:10 P.M., showed Certified Nurse Aide (CNA) G and CNA H entered the resident's room to provide perineal care on the resident. CNA G applied gloves, transferred the resident to bed, performed catheter care then removed his/her gloves. Observation showed CNA G did not wash his/her hands and applied clean gloves. Observation showed CNA G provided care to the resident's buttocks, removed his/her gloves, applied clean gloves and repositioned the resident. Observation showed CNA G did not wash his/her hands between glove changes. Observation showed CNA H picked up the resident's nasal cannula oxygen tube from the floor and draped it over the side rail. Observation showed CNA G applied the oxygen to the resident's nose.
During an interview on 12/13/23 at 02:10 P.M., CNA G said he/she should have washed his/her hands between glove changes and when entering the room. He/She said he/she was really nervous he/she was being watched and forgot. CNA G said he/she did not know the tubing was on the floor but if he/she did he/she would have obtained a new one and applied it instead. He/She said oxygen tubing on the floor is not sanitary.
During an interview on 12/13/23 at 02:32 P.M., CNA H said he/she should have got a new oxygen tube for the resident and never let CNA G apply it to the resident because of infection risk. He/She said he/she was nervous and would get the resident a new tubing.
During an interview on 12/14/23 at 09:12 A.M., the DON said staff are expected and educated to wash their hands between glove changes to prevent the spread of infection. Also staff are expected to change oxygen tubing if found on the floor or at least make sure it was cleansed for infection control reasons.
5. Review of the facility's policies showed staff did not provide a policy on oxygen tubing changes or cleaning of equipment.
6. Review of Resident's #15's quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Oxygen therapy;
-Diagnosis of hypertension, anxiety disorder, bipolar disease, asthma, respiratory failure.
Review of the resident's Physicians Order Sheet (POS), dated 9/15/23, showed tubing to be replaced and labeled with the date once a day on Wednesday during the night shift.
Observation on 12/13/23 at 11:06 A.M., showed the resident's oxygen tube undated.
Observation on 12/14/23 at 8:29 A.M., showed the resident's oxygen tubing was dated for 12/13/23.
7. Review of Resident's #20's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Oxygen therapy;
-BiPAP therapy (a device that helps with breathing which provides distinct air pressure levels for inhalation and exhalation);
-Diagnoses of chronic lung disease, respiratory failure, anxiety, heart failure, and a fracture.
Review of the resident's POS, dated 12/01/23, showed the record did not contain an order change the oxygen tubing for the BiPAP machine, or oxygen concentrator.
Observation on 12/11/23 at 01:04 P.M., showed the resident used oxygen per a nasal cannula. Observation showed the BiPAP tubing and oxygen concentrator tubing undated.
Observation on 12/12/23 at 08:24 A.M., showed the resident used oxygen per a nasal cannula. Observation showed the BiPAP tubing and oxygen concentrator tubing undated.
8. Review of Resident's #59's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Oxygen therapy;
-Diagnoses of chronic lung disease, and heart failure.
Review of the resident's POS, dated 12/01/23 showed an order for tubing to be replaced and labeled with the date once a day on Friday.
Observation on 12/11/23 02:15 P.M., showed the resident used oxygen per a nasal cannula. The breathing treatment tubing and oxygen concentrator tubing undated.
Observation on 12/12/23 at 10:11 A.M., showed the resident used oxygen per a nasal cannula. The breathing treatment tubing and oxygen concentrator tubing undated.
During an interview on 12/12/23 at 2:46 P.M., CNA O said the night shift changes tubing.
During an interview on 12/12/23 at 3:00 P.M., the DON said the night shift should change and date oxygen tubing once a week.
During an interview on 12/14/23 at 08:53 A.M., LPN A said if a resident has oxygen therapy, treatments with a nebulizer or BiPAP, orders should be in place to clean and date the equipment weekly.
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 staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. Fa...
Read full inspector narrative →
Based on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. Facility staff also failed to store food in a manner to prevent contamination and out-dated use. The facility census was 71.
1. Review of the facility's Machine Warewashing policy, dated November 2017, showed the policy directed staff to air dry all items and ensure all items are completely dry before stacking to prevent wet-nesting.
Observation on 12/11/23 at 9:54 A.M., showed Dietary Aide (DA) I removed sanitized plates from the clean side of the mechanical dishwashing station while wet and stacked them together upside down in the plate heater. Observation showed the DA removed sanitized insulated plate holders and domed plate covers from the clean side of the station while wet and stacked them together in the upright position on a service cart.
Observation on 12/11/23 at 10:25 A.M., showed DA I removed sanitized insulated plate holders and domed plate covers from the clean side of the mechanical dishwashing station while wet and stacked them together on the service cart.
During an interview on 12/11/23 at 10:28 A.M., the Certified Dietary Manager (CDM) said DA I started his/her employment at the facility almost two months ago and he/she trained the DA to allow dishes to air dry before they were put away.
Observation on 12/11/23 at 10:39 A.M., showed the food and beverage service station contained:
-22 insulated bowls stacked together wet on the shelf above steamtable;
-16 plastic service trays stacked together wet on the drink counter;
-24 black insulated coffee cups stacked together wet shelf above drink counter;
-24 tall clear plastic glasses stacked together wet by coffee cups;
-21 clear plastic juice glasses stacked together wet below the tall glasses glasses;
-26 insulated domed plate covers stacked together wet in the service window.
Observation on 12/11/23 10:51 AM showed [NAME] L used the one of the tall clear plastic wet stacked glasses to prepare a glass of soda for a resident.
Observation on 12/11/23 during the lunch meal service which began at 12:00 P.M., showed DA J and [NAME] L used the wet stacked cups, glasses, service trays, insulated plate holders and domed plate covers to serve food to residents.
Observation on 12/13/23 at 9:21 A.M., showed DA K removed sanitized plastic service trays, insulated bowls, domed plate covers and insulated plate holders from the clean side of the mechanical dishwashing station while wet, stacked them together and put them away.
During an interview on 12/13/23 at 9:26 A.M., the CDM said staff should allow dishes to air dry before they are put away and they are trained on this requirement. The CDM said he/she is responsible to monitor dishwashing procedures, which he/she does at random when he/she take dishes to the station, but he/she normally looks for cleanliness and not water.
During an interview on 12/13/23 10:06 A.M., the administrator said dishes should be air dried before they are put away and the CDM should have trained all staff who wash dishes to allow them to air dry. The administrator said the CDM is responsible to monitor the way the dishes are washed and put away as needed when he/she is on duty and the cooks would be responsible to monitor it when the CDM is not on duty.
2. Review of the facility's Dry Storage policy, dated November 2017, showed the policy directed staff to securely close opened food packages to protect the product. Review showed the policy did not include information related to the dating of opened food items to prevent out-dated use.
Review of the facility's Refrigerator and Freezer Storage policy, dated November 2017, showed the policy directed staff to store foods in their original containers, National Sanitation Foundation (NSF) approved container or wrapped tightly in moisture-proof film, foil, etc. and clearly label the food item with the contents and use by date. Review showed leftovers will be placed in NSF approved containers, covered, labeled, dated and stored in refrigerator or freezer at correct temperature.
Observation on 12/11/23 at 9:58 A.M., showed the dry goods pantry contained:
-opened and undated bags of egg noodles, elbow macaroni, spaghetti, cornflakes and toasted oats cereal;
-opened and undated one gallon bottles of white vinegar, red wine vinegar, apple cider vinegar, soy sauce, corn syrup, pancake syrup and Worcestershire sauce;
-an opened and undated 12 ounce (oz.) box of gluten free penne pasta;
-an opened and undated 14.4 oz. box of graham crackers;
-an opened and undated 32 oz. bottle of browning sauce;
-an opened and undated one quart canister of toasted sesame oil;
-an opened and undated 68 oz. bottle of olive oil;
-an opened and undated six pound bottle of honey;
-an opened and undated 58 oz. carton of potato pearls;
-an undated 36 oz. box of iodized salted opened to the air.
During an interview on 12/11/23 at 10:03 A.M., the CDM said staff are expected to date any opened unused food items.
Observation on 12/11/23 at 10:11 A.M., showed an opened and undated bag of boneless chicken breast strips in the three door reach-in freezer. Observation also showed a sign posted on the freezer door which read Date all items after opening Leftovers and other refrigerated items date 3 days out, do not use after that date. Dry goods, seasoning & spices, gallon size condiments & dressings, and frozen items put a opened on date. Most items that fall in there are good for a year. Even snacks that are not prepackaged including sandwiches need dated for 3 days out.
Observation on 12/11/23 at 10:21 A.M., showed an opened and undated one gallon bottle of vegetable salad oil on the stand mixer in the cook's station.
Observation on 12/11/23 at 10:39 A.M., showed a bin of coffee filters filled with coffee grounds uncovered on the cart by the coffee pot and a bin of ice opened which exposed the ice to the air. Observation showed the ice scoop holder attached to the bin in a manner which did not allow the bin's cover to close.
Observation on 12/11/23 at 10:51 A.M., showed [NAME] L used the ice from the opened bin to prepare a glass of soda for a resident.
During an interview on 12/13/23 at 9:26 A.M., the CDM said opened food items should be labeled, dated and sealed before they are put away and staff are trained on this requirement upon hire and annually. The CDM said he/she is responsible to monitor the food storage and he/she tries to look at it every day he/she is there, but he/she routinely looks at it on food delivery days twice a week. The CDM said he/she did not notice the lid to the ice bin did not close.
During an interview on 12/13/23 at 10:02 A.M., the administrator said staff should date opened food items and store them sealed. The administrator said all staff go through the pineapple training program and food storage requirements should be something that is covered in that program. The administrator said the CDM is responsible to monitor the food storage daily when in the building and the cooks are responsible to monitor it when the CDM not in the building.
Oct 2023
1 deficiency
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential ...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of Covid-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for Covid-19. The facility failed to separate three positive Covid-19 residents (Resident #1, #3 and #8) from residents who had tested negative for Covid-19 or had only been exposed to Covid-19 for five residents (Resident #2, #4, #5, #6 and #7) at an increased risk of contracting Covid-19 due to prolonged exposure. The facility census was 71.
The Administrator was notified on 10/02/23 at 1:43 P.M., of an Immediate Jeopardy (IJ) which began on 09/19/23. The IJ was removed on 10/02/23 as confirmed by surveyor onsite verification.
Review of the Center's for Disease Control (CDC's) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 5/8/23, showed a patient with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Facilities could consider designating entire units within the facility, with dedicated health care personnel (HCP), to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. The Infection prevention and Control (IPC) recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Source control is recommended for individuals in healthcare settings who have had close contact (patients and visitors) or a higher-risk exposure with someone with SARS-CoV-2 infection, for 10 days after their exposure.
Review of the facility's Coronavirus (COVID-19) Policy, revised May 2023, showed staff are directed to effectively cohort residents with separate areas with dedicated COVID-19 care. Review showed the facility is directed to follow the CDC recommendations related to COVID-19. Review of the facility policy did not contain directions for asymptomatic residents in regards to quarantine protocols.
1. Review of Resident #1's COVID test results form, dated 09/25/23, showed a positive result.
Observation on 10/02/23 at 08:30 A.M., showed Resident #1 who tested positive for COVID on 09/25/23 in a room with Resident #2 who tested negative for COVID on 09/19/23 and 09/25/23. Observation showed Resident #1 and #2 did not have a face mask on. The door to the residents room was open.
During a telephone interview on 10/05/23 at 12:10 P.M., Resident #2's relative said he/she expected staff to move a resident who tested positive for COVID-19 out of a room of someone who tested negative.
2. Review of Resident #3's COVID test results form, dated 09/19/23, showed a positive result.
Review of Resident #4's COVID test results form, dated 09/19/23, showed a negative result. Review of the resident's COVID test results form, dated 9/25/23, showed a positive result.
Review of Resident #5's COVID test results form, dated 09/19/23, showed a negative result. Review of the resident's COVID test results form, dated 9/25/23, showed a positive result.
Review of Resident #6's COVID test results form, dated 09/19/23, showed a negative result. Review of the resident's COVID test results form, dated 9/25/23, showed a negative result.
Observation on 10/02/23 at 8:37 A.M., showed Resident #3, who tested positive for COVID on 09/19/23 and Resident #4, and Resident #5 who tested positive for COVID on 09/25/23 occupied in the same room with Resident #6 who tested negative for COVID on 09/19/23, and 09/25/23. Observation showed Resident #3, Resident #4, Resident #5 and #6 did not have a face mask on. Observation showed the residents' door did not have a sign on the door. Observation showed Resident #3 had a cough and shortness of breath.
Observation on 10/02/23 at 5:30 P.M., showed Resident #6 in the main dining room as he/she sat at a table with three other residents without a mask.
During a telephone interview on 10/05/23 at 1:10 P.M., Resident #6's relative said he/she was never notified by the facility they had a COVID outbreak, but that he/she would have expected staff to move a resident who tested positive for COVID-19 out of a room of someone who tested negative.
5. Review of Resident #8's COVID test results form, dated 09/25/23, showed a positive result.
Review of Resident #7's COVID test results form, dated 09/19/23, showed a negative result. Review of the resident's COVID test results form, dated 9/25/23, showed a negative result.
Observation on 10/02/23 at 8:42 A.M., showed Resident #8 who tested positive for COVID on 09/25/23 in a room with Resident #7 who tested negative for COVID on 09/19/23, and 09/25/23. Observation showed Resident #7 and #8 did not have a face mask on. Observation showed Resident #8 had a productive cough.
Observation on 10/02/23 at 5:45 P.M., showed Resident #7 in the hallway near the dining room without a mask on.
6. During an interview on 10/02/23 at 09:15 A.M., the Director of Nurses (DON) said they were advised not to move any of the residents who tested positive for COVID by the administrator. He/She said there was no reason given other than he/she did not want to move them. He/She said they did not ask residents who were negative if they would like to move because they were instructed not to move residents.
During an interview on 10/02/23 at 9:48 A.M., Certified Medication Technician (CMT) A said he/she is one of the staff members responsible to handle COVID and is the one who does all the tests. He/She said they chose not to move the residents because most of them did not feel sick so they were allowed to move about the facility as they chose and they did not wear masks. He/She said they did not ask residents who were negative if they would like to move because they were instructed not to move residents.
During an interview on 10/02/23 at 10:35 A.M., the Minimum Data Set (MDS) Coordinator said they were in contact with their corporate office who sent them a copy of their updated policy from May 23 which said if residents weren't symptomatic then they did not have to quarantine so that is why they did not move any of the residents.
During an interview on 10/02/23 at 10:50 A.M., the administrator said he/she and the nursing staff decided not to move residents when they had positive results because it was more detrimental to them to move then rather to not move them. He/She said over the past three to four years he/she has been in homes and to move them has increased the spread of the disease rather than to decrease it. He/She said he/she felt their psychosocial risk were more at risk by moving them.
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).
MO00224755
Feb 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 observation, interview, and record review, facility staff failed to ensure one resident (Resident #2) remained free fro...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #2) remained free from physical abuse, when another resident (Resident #1) hit the resident on the head with a metal object. The facility staff also failed to communicate to oncoming staff Resident #1 showed signs of agitation prior to incident. The facility census was 70.
Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 2/1/23, showed:
-Abuse, Neglect, Misappropriation of Patient Property and Exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor of any other individual in this center. The patient has the right to be free from abuse, neglect, misappropriation of patient property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patients medical symptoms.
-Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Includes: verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
-Physical abuse: includes hitting, slapping, pinching and kicking.
-Mental abuse: Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation.
Review of the facility's internal investigation report, dated 2/8/23, showed staff documented Resident #2 headed to or from the bathroom and got too close to Resident #1. Resident #1 grabbed reachers and started to hit Resident #2. Staff separated the residents. Staff sent Resident #2 sent to the Emergency Room. Staff held an emergency meeting on 2/9/23 and issued an emergency discharge notice to Resident #1.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/5/22, showed facility staff assessed the resident as follows:
-Cognitively impaired;
-No behaviors;
-Diagnoses including Alzheimer's disease, Dementia and impulse disorder;
-Wheelchair and walker use for mobility.
Review of the resident's plan of care, dated 1/06/22, showed staff assessed the resident with potential for alteration in mood/behaviors, at risk for complications due to diagnoses of Impulse disorder, Alzheimer's, Depression, history of physically and verbally aggressive behavior towards staff and other residents. Staff were directed to approach resident in a calm, friendly manner, monitor effects and effectiveness of medications and side effects, to notify the physician with mood changes or behaviors, removed from any situations that could escalate behaviors, be direct and prompt when telling the resident his/her behaviors are inappropriate and calmly reassure resident.
Review of Resident #1's nurse's notes showed staff documented:
-On 2/8/23 at 8:40 P.M., Staff heard a loud commotion coming from the resident's room. Staff entered the resident's dark room to see the resident hitting his/her roommate over the head several times with two metal grabbers. Staff intervened and removed the grabbers. Staff removed the resident's roommate from the room. Resident #1 reported, He/She jumped on my outfit, pointing to the wheelchair, and I told him/her to quit it. My clothes fell on the ground. The resident said his/her roommate did not listen to him/her and they started fighting. He/She said his/her roommate knocked his/her things off the table so Resident #1 took his/her forks (pointing to the metal grabbers) and wrapped them around his/her neck.
-On 2/9/23 at 10:20 A.M., The Director of Nursing (DON) documented an entry for 02/08/23. The DON documented Resident #1 became violent towards his/her roommate, striking him/her on his/her head causing lacerations that required an emergency room visit for evaluation and treatment. Review showed staff documented this was not the first time Resident #1 had behaviors that were violent.
-On 2/9/23 at 10:25 A.M., staff documented they issued an emergency discharge notice to Resident #1 due to continuous resident-to-resident incidents.
Review of Resident #2's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows:
-Severely cognitively impaired;
-No behaviors;
-Diagnosis of Dementia;
-Independent with mobility.
Review of the resident's plan of care, dated 1/17/23, showed staff documented the resident had a diagnoses of dementia with periods of confusion. Staff were directed to approach at a different time when resident does not comply, ask how to make the resident more comfortable, assess behaviors and try to determine cause, assess for stressors in the environment, assess if patients anxiety is in response to fear, helplessness, or disruptions or changes in life, be direct and prompt when telling the resident a behavior is inappropriate, explain all procedures beforehand, observe for signs of increasing hostility, restrict harmful physical action in a cautious, non-harmful manner and monitor for increased confusion or agitation.
Review of the resident's nurses notes, dated 02/08/23, showed staff documented staff heard a loud commotion coming from the resident's room. Staff entered the room to see Resident #1 hitting Resident #2 over the head several times with two metal grabbers. Staff intervened, removed the grabbers, and removed Resident #2 from the room. Staff cleaned Resident #2's head wounds and applied a pressure dressing. The resident said, He/She just started [NAME] on me and he/she did not know why. Staff documented they assessed bruising on his/her left thumb, left 3rd finger, and right thumb as well as several small cuts on the top of his/her head. Staff notified the resident's physician and the Director of Nursing (DON).
Review of the resident's nurses notes, dated 2/9/23, showed staff documented the resident returned from the emergency room at 10:45 P.M. Stable condition and verbally alert and responsive. Vital signs stable and afebrile. Had small bandages to areas on head. No active bleeding at this time. Able to transfer into bed with one assist and has been resting without distress to present. No chief complaint of pain or discomfort voiced. At hospital negative for any abnormal findings.
Review of Resident #2's hospital records, dated 2/8/23, showed the resident recieved steri strips to the head and CT negative for abnormal findings.
Review of the resident's nurses notes, dated 2/11/23, showed staff documented the resident was content and laying in bed. The resident chief complaint is his/her head being slightly sore while the nurse applied the antibiotic ointment to the small abrasions on his/her head.
Review of the resident's nurses notes, dated 2/12/23 staff documented the nurse was asked to go to the residents room due to resident being upset about being hit by former roommate. Staff entered resident room and resident was in wheelchair. Roommate in bed. Resident didn't recognize that roommate was a different person. Staff explained to resident that resident was safe and he/she had a new roommate and the new roommate would not hurt him/her. Resident stated, So you will be my guard! Resident laughed, was assisted back to bed and slept through the night.
Observation on 2/22/23 at 10:55 A./M., showed Resident #2 in bed with lacerations on his/her head and bruising on his/her face, arms, and hands.
During an interview on 2/22/23 at 8:52 A.M., the DON said this was not Resident #1's first combative episode. They sent Resident #2 to the emergency room with three lacerations on his/her head.
During an interview on 2/22/23 at 10:05 A.M., Resident #1's Durable Power of Attorney (DPOA) said the resident has a tendency to be combative, especially at night, and believed this could be part of his/her Post Traumatic Stress Disorder (PTSD).
During an interview on 2/22/23 at 10:43 A.M., Certified Nursing Assistant (CNA) A said Resident #1 was grumpy and very combative at times. The evening of the altercation he/she said he/she could tell Resident #1 was agitated, but it was shift change and he/she left. He/She said after the incident Resident #2 was confused about the lacerations to his/her head, the resident got a new roommate and he/she was very scared of new roommate, because of past roommate Resident #1.
During an interview on 2/22/23 at 10:49 A.M., Registered Nurse (RN) C said Resident #1 was on Seroquel (an antipsychotic used to treat schizophrenia, bipolar disorder and depression) and Sertraline (a serotonin reuptake inhibitor used to treat depression, obsessive-compulsive disorder (OCD), PTSD, social anxiety disorder, and panic disorder) to help combat behaviors along with psych charting. He/She said the staff just monitored the resident, but was unsure of his/her triggers. He/She said Resident #2 was confused and scared after the incident occured.
During an interview on 2/22/23 at 11:02 A.M., Certified Medication Technician (CMT) B said he/she did not work during the incident. He/She said Resident #1 could be combative, but was not aware of what interventions were in place.
During an interview on 2/22/23 at 12:08 P.M., the Administrator said Resident #1 had previous altercations. He did not know what interventions were in place for Resident #1's combative behavior.
During an interview on 2/28/23 at 6:36 A.M., Licensed Practical Nurse (LPN) F said CMT G said he/she heard commotion and went into the residents' room to find Resident #1 beating Resident #2 in the head with his/her metal grabbers. He/She sent Resident #2 to the hospital for treatment and evaluation for his/her head wounds. He/She did not personally have problems with Resident #1 being aggressive or combative, but knew he/she had a reputation of that when his/her spouse was alive, hitting other residents and staff to the point of requiring a haldol injection. Resident #1's triggers were the dark, not hearing/understanding and getting out of routine. Resident #1 needed to be approached in a gentle manner to not startle him/her. He/She said no one at shift change relayed to him/her that Resident #1 showed signs of combative behavior or aggression and that was something he/she would expect to know.
During an interview on 2/28/23 at 9:56 A.M., CMT G said he/she heard commotion in Resident #1 and Resident #2's room, he/she walked into the room and witnessed Resident #1 hitting Resident #2 in the head with his/her metal grabbers and he/she stopped it. Resident #2 was bleeding from the head profusely and sent to the hospital for evaluation and treatment. He/She said he/she has never seen Resident #1 be physically combative but knew he/she had a history of being aggressive. He/She said no staff alerted him/her to Resident #1 showing aggressive behaviors and he/she was not sure of what interventions were in place to watch or prevent aggressive combative behavior.
MO00213782
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide an appropriate discharge notice to one resident (Resident #1) who the facility issued an emergency discharge notice. Staff failed t...
Read full inspector narrative →
Based on interview and record review, the facility failed to provide an appropriate discharge notice to one resident (Resident #1) who the facility issued an emergency discharge notice. Staff failed to provide the notice to the resident's Durable Power of Attorney (DPOA), failed to include the reason for the discharge, failed to include an appropriate discharge location, failed to include the information on how to appeal the discharge, and failed to allow the resident to return to the facility after a hospital stay. The facility census was 70.
1. Review of the facilty's discharge procedures, revised 6/2006, showed the intent of discharge planning is to make advance decisions anticipating the enviornment most suitable for meeting the patient's medical, social, emotional and financial needs, reflecting expectations of the patient, family and physician.
Review of the facility's patient care policies Transfer/Discharge, revised 2/2022, showed:
-A patient may be transferred or discharged to another health care institution or discharged home upon the written order of the attending physician;
-Sufficient information will be provided to the patient to assure continuity of care, regardless of the destination of the patient or the reason for transfer;
-The center shall seek transfer or involuntary discharge of the patient only under circumstances allowed by State and Federal law. Involuntary transfers will follow guidelines provided by the State for assuring adequate patient protection;
-A physician's discharge order which is opposed by the patient or responsible party is considered and treated as an involuntary disharge;
-In the event there are issues regarding care that cannot be resolved, the center acknowledges the right of the patient or responsible party to arrange for accomodations elsewhere. The center will assist in effecting a smooth transition.
2. Review of Resident #1's emergency discharge notice, dated 2/9/23, showed staff documented the discharge effective immediately and discharged to care of the resident's Durable Power of Attorney (DPOA) E. Review showed the discharge notice did not contain:
-A letter addressed to the DPOA D & E;
-Specific information related to the reason for the emergency discharge;
-An appropriate location to which the resident was discharged ;
-A statement of the resident's appeal rights, including the telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
-The correct information for the regional Long-Term Ombudsman.
Review of the resident's nurses notes, dated 2/9/23, showed the Director of Nursing (DON) documented staff held an emergency meeting regarding the resident's behavior from the prior evening. The resident became violent towards his/her roommate, striking him/her on the head with a metal object, causing lacerations that required an emergency room visit for evaluation and treatment. The DON documented this was not the first time the resident had violent behaviors and they determined the resident would benefit from a psychiatric evaluation. Staff transferred the resident to a local emergency room and sent the resident with a discharge letter so the resident would not return to facility.
During an interview on 2/22/23 at 9:37 A.M., the resident's DPOA D said there were two DPOAs, he/she shares DPOA with his/her sibling. He/She said the emergency discharge was not given to him/her nor DPOA E and they were unaware they had the right to appeal. He/She said the Director of Nursing (DON) told them the resident could not return to the facility. He/She said the resident previously lived with him/her but the resident progressed into needing 24-hour care and he/she could not provide that because he/she worked. He/She said his/her home has stairs and the resident utilized a wheelchair. He/She said no one from the facility checked to make sure his/her house was safe for the resident or contacted home health.
During an interview on 2//23/23 at 9:49 A.M., the DON said the resident needed 24-hour care. The DON said the resident could not bathe himself/herself, cook, or administer his/her own medications. There was no home assessment or conversation with home health because the resident was just released into the care of DPOA E. The facility was not aware of where he/she would go once he/she left the local hospital.
During an interview on 2/23/23 at 10:05 A.M., the resident's DPOA E said he/she never received a discharge notice, got a phone call that the resident was discharged to the local hospital, and was not aware he/she could appeal the decision because the DON said it was immediate. The resident needs 24-hour care, DPOA E works full time, and his/her house has stairs. The resident must use a wheelchair or walking device. DPOA E said, We do not have the choice to take him/her home. There was no home assessment done nor did home health contact them. The local hospital found placement for the resident, but he/she was an hour-and-a-half away from them. Now that facility wants to discharge him/her and we have no where for him/her to go.
During an interview on 2/23/23 at 10:43 A.M., CMT A said the resident could not walk down stairs.
During an interview on 2/23/23 at 10:49 A.M., CMT B said the resident had poor safety awareness.
During an interview on 2/23/23 at 12:08 P.M., the administrator said they sent the emergency discharge with the resident to the hospital and talked to the resident's DPOAs on the phone. The resident does need 24-hour care, but they did not set up home health or complete other discharge planning. The DON said they just released the resident into the care of DPOA E.
MO00214405
Sept 2022
14 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the resident environment remains as free of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the resident environment remains as free of accident hazards as is possible, when staff failed to maintain the hot water temperature of plumbing fixtures accessible to residents on corridors A and B in a manner to prevent serious burns or scalding in a short amount of time. Additionally, facility staff failed to ensure razors and hazardous chemicals were stored in a safe manner, and failed to lock an unattended treatment cart. Facility staff also failed to propel four residents (Residents #14, #30, #57 and #59) in wheelchairs in a manner to prevent accidents. The facility census was 68.
The administrator was notified on 09/20/22 at 12:45 P.M. of an Immediate Jeopardy (IJ) which began on 09/19/22. The IJ was removed on 09/20/22, as confirmed by surveyor onsite verification.
1. Review of the facility's Water Temperature Policy, undated, showed the policy directed staff to check water temperatures in the kitchen, maintenance room, housekeeping room, central supply room and at least two rooms per hall once weekly and record the temperatures in the water temperature binder. Review showed the policy directed staff to adjust the water temperature accordingly if the water temperature measured outside the range of 105 to 120 degrees Fahrenheit (dF).
Review of the facility's Weekly Domestic Hot Water Temperature Check log dated 09/05/22, showed the maintenance director documented:
-Tank Location
Building Area Supplied
Supply Temperature dF
*Housekeeping
Laundry
120
D Wing
NA
C Wing
120
*Central Supply
A&B Wing
120
*Maintenance Office
Kitchen
120
Domestic
120
Review showed the record did not contain documentation of the water temperature in two rooms per hall as directed by the facility policy.
Review of the facility's Weekly Domestic Hot Water Temperature Check log dated 09/12/22, showed the maintenance director documented:
-Tank Location
Building Area Supplied
Supply Temperature dF
*Housekeeping
Laundry
115
D Wing
NA
C Wing
115
*Central Supply
A&B Wing
120
*Maintenance Office
Kitchen
120
Domestic
120
Review showed the record did not contain documentation of the water temperature in two rooms per hall as directed by the facility policy.
Review of Resident #12's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 06/08/22, showed staff documented the resident's score for the Brief Interview for Mental Status (BIMS), a screening tool used to detect cognitive impairment, as 00 (severe impairment).
Review of Resident #17's MDS, dated [DATE], showed staff documented the resident's diagnoses included diabetes mellitus and the resident's score for the BIMS as 11 (moderately impaired).
Review of Resident #46's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease and dementia and the resident's score for the BIMS as 12 (moderately impaired).
Observation on 09/19/22 at 12:10 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #12, #17 and #46 measured 147.7 dF when tested for two minutes with a calibrated metal stem-type thermometer.
During an interview on 09/19/20 at 4:13 P.M., the Director of Nursing (DON) said Resident #12 is alert, but non-verbal so his/her cognitive orientation is difficult to determine. The DON said if the resident got in extremely hot water without staff supervision the resident would not react and pull his/herself out of the water. The DON said Resident #17 is alert and oriented, but he/she would not react if his/her feet were in extremely hot water due to sensation loss from diabetes. The DON said the resident uses an electric wheelchair and is able to operate the wheelchair independently. The DON also said Resident #46 is alert to person and place, but not time. The DON said the resident is able to propel himself/herself in a wheelchair for short distances, and would be able to propel him/herself into bathroom.
Review of Resident #19's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease and dementia. Staff documented the resident would not be able to complete a BIMS as the resident was rarely/never understood. Staff assessed the resident with memory problems for both short term and long term memory and had severely impaired cognitive skills for daily decision making. Staff assessed the resident with inattention and disorganized thinking behaviors.
Review of Resident #316's MDS, dated [DATE], showed staff documented the resident's diagnoses included diabetes mellitus and dementia and the resident's score for the BIMS as 00 (severe impairment).
Observation on 09/19/22 at 12:17 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #19 and #316 measured 145.2 dF when tested for two minutes with a calibrated metal stem-type thermometer.
During an interview on 09/19/22 4:18 P.M., the DON said Resident #19 is alert, but only oriented to himself/herself. The DON said the resident does ambulate independently and wanders throughout the facility. The DON also said Resident #316 is alert to only himself/herself and able to ambulate independently at times depending on the time of day and his/her mood.
Review of Resident #26's MDS, dated [DATE], showed staff documented the resident's diagnoses included cerebrovascular accident (stroke) and a seizure disorder. The staff documented the resident's score for the BIMS as 05 (severe impairment).
Review of Resident #315's physician orders, dated September 2022, showed the resident's diagnoses included dementia. Continued review of the resident's medical records showed the records did not contain documentation of an assessment of the resident's cognition.
Observation on 09/19/22 at 12:26 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #26 and #315 measured 146.5 dF when tested for two minutes with a calibrated metal stem-type thermometer.
During an interview on 09/19/22 4:21 P.M., the DON said #26 is alert to himself/herself, time and sometimes place, but needs redirection/reorientation at times. The DON said the resident ambulates independently with with a wheeled walker. The DON said he/she did not know much about Resident #315 since he/she was admitted a week ago while he/she was away, but the resident ambulates independently with a wheeled walker. The DON said he/she did not know if the resident would be able to remove him/herself from extremely hot water.
Review of Resident #6's MDS, dated [DATE], showed staff documented the resident's diagnoses included dementia and the resident's score for the BIMS as 05 (severe impairment).
Review of Resident #42's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease and the resident's score for the BIMS as 01 (severe impairment).
Observation on 09/19/22 at 12:32 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #6 and #42 measured 148.3 dF when tested for two minutes with a calibrated metal stem-type thermometer.
During an interview on 09/19/22 4:31 P.M., the DON said Resident #6 is only alert to himself/herself at times and ambulates independently. The DON said Resident #42 is only alert to himself/herself and is able to propel him/herself in a wheelchair.
Review of Resident #23's MDS, dated [DATE], showed staff documented the resident's diagnoses included diabetes mellitus and the resident's score for the BIMS as 05 (severe impairment).
Review of Resident #65's physician orders, dated September 2022, showed the resident's diagnoses included unspecified dementia without behavioral disturbances.
Review of Resident #317's MDS, dated [DATE], showed staff documented the resident's diagnoses included diabetes mellitus and the resident's score for the BIMS as 05 (severe impairment)
Observation on 09/19/22 at 12:35 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #23, #65 and #317 measured 141.1 dF when tested for two minutes with a calibrated metal stem-type thermometer.
During an interview on 09/19/22 at 4:26 P.M., the DON said Resident #23 is alert only to himself/herself and has limited mobility. If the resident got in extremely hot water without staff supervision, the resident would not be able to remove himself/herself from the water. The DON said Resident #65 is alert only to himself/herself at times and is able to propel him/herself independently in a wheelchair. The DON also said Resident #317 is alert only to himself/herself and is able to propel himself/herself in a wheelchair. He/she believed the resident would recognize extremely hot water, but he/she would not be able to remove himself/herself from the hot water.
Review of Resident #7's MDS, dated [DATE], showed staff documented the resident's diagnoses included dementia and diabetes mellitus and the resident's score on the BIMS as 00 (severe impairment).
Review of Resident #13's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease, dementia, stroke and diabetes mellitus. Further review showed staff documented the resident's score for the BIMS as 00 (severe impairment).
Observation on 09/19/22 at 12:45 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #7 and 13 measured 147 dF when tested for two minutes with a calibrated metal stem-type thermometer.
During an interview on 09/22/22 at 10:50 A.M., the DON said Resident #13 is alert only to him/herself and if he/she got in extremely hot water without staff supervision he/she would not be able to get him/herself out of the water. The DON said resident #7 is not oriented and non-verbal. He/she believed the resident would recognize if the water was too hot, because he/she does respond to physical stimuli, but if the resident got in extremely hot water he/she would not be able to get his/herself out of the water.
Review of Resident #4's MDS, dated [DATE], showed staff documented the resident would not be able to complete a BIMS as the resident was rarely/never understood. Staff assessed the resident with memory problems for both short term and long term memory and had severely impaired cognitive skills for daily decision making. Staff assessed the resident with inattention, disorganized thought, and an altered level of consciousness.
Review of Resident #14's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease. Staff documented the resident would not be able to complete a BIMS as the resident was rarely/never understood. Staff assessed the resident with memory problems for both short term and long term memory and had severely impaired cognitive skills for daily decision making.
Review of Resident #22's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease and dementia and the resident's score for the BIMS as 01 (severe impairment).
Observation on 09/19/22 at 12:47 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #4, #14 and #22 measured 148.8 dF when tested for two minutes with a calibrated metal stem-type thermometer.
During an interview on 09/22/22 at 10:50 A.M., the DON said Residents #4 and #14 are alert only to themselves and he/she believed the residents would recognize the water was too hot, but they would not easily be able to remove themselves from the water. The DON said Resident #22 is alert only to him/herself and he/she believed the resident would recognize if the water was too hot, but he/she would not be able to remove him/herself from the water at all.
Observation on 09/19/22 at 1:18 P.M., of the thermometer for the two 108 gallon hot water heater holding tanks for corridors A and B, where the resident rooms were located, showed the temperature of the water measured 129 dF.
During an interview on 09/19/22 at 1:27 P.M., the Maintenance Director said he/she looks at the gauges on the water heaters and checks one room on each hall in addition to the kitchen, laundry and a common area weekly. He/she does not document the temperatures of the water tested from the plumbing fixtures on each hall, but they should not be greater than 125 dF. He/she had worked at the facility for two years and the previous maintenance director who trained him/her told him/her that 125 dF is the maximum hot water temperature allowed by regulations.
Observation on 09/19/22 at 2:00 P.M., showed the temperature of the hot water from the shower head in the common shower room measured 146.5 dF.
During an interview on 09/19/22 at 2:10 P.M., the administrator said he/she would expect staff to check the water temperatures in two to three rooms and common areas weekly. The administrator said staff should also document each temperature and area measured. The maximum water temperature allowed by regulation is 120 dF and he/she did not know the maintenance director did not know that.
2. Review of the facility's Hazardous Materials Policy, revised November of 2017, showed it did not contain direction for staff in regard to hazardous chemical storage.
Review of the facility's Administration Procedures for All Medications Policy, dated 1/1/19, showed all medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/technician.
Observation on 9/21/22 at 8:21 A.M., showed an unlocked and unattended treatment cart on C hallway.
Observation on 9/21/22 at 8:29 A.M., showed an unlocked and unattended treatment cart on C hallway.
Observation on 9/21/22 at 8:31 A.M., showed two staff members walked by the unlocked treatment cart on C hallway.
Observation on 9/21/22 from 8:38 A.M. to 8:48 A.M., showed the unlocked and unattended treatment cart contained:
-Five lancets (For blood sampling);
-Two tubes of antifungal cream labeled, Contact poison control if ingested;
-Two tubes of Biofreeze (Medication for muscle or joint pain);
-Two containers of Nystatin powder (Treats fungal or yeast infections of the skin);
-One bottle of Hydrogen Peroxide 3% (Antiseptic) labeled, Contact poison control if ingested;
-One bottle of first aid antiseptic povidone-iodine solution 10% labeled, Contact poison control if ingested;
-One tube of mupirocin ointment 2% (Ointment to treat skin bacteria) labeled, Contact poison control if ingested;
-One tube of neosporin (Ointment to treat skin bacteria) labeled, Contact poison control if ingested;
-One tube of Calazinc Body Shield (Skin protectant) labeled, Contact poison control if ingested; and
-Multiple packets of Povidone-iodine 10% (Antiseptic) swabs labeled, Contact poison control if ingested.
Observation on 9/21/22 at 8:50 A.M., showed ten staff members walked by the treatment cart as this surveyor documented it's contents. The DON locked the treatment cart.
During an interview on 9/22/22 at 2:00 P.M., Certified Nurse Aide (CNA) C said if staff see an unlocked treatment cart, they should lock it and then notify the nurse.
During an interview on 9/23/22 at 12:17 P.M., the DON said staff are expected to lock the treatment cart before they leave it. He/ She said, Anyone could get into it, and a confused resident could get something and lick it.
3. Observation on 9/20/22 at 8:39 A.M., showed the C hallway shower room unlocked and unattended with a hair dryer plugged in, a disposable razor on the sink, and a disposable razor in the shower. Further observation showed two unlocked and unattended cabinets that contained:
-Mycolic disinfecting wipes labeled, Call poison control or doctor for treatment advice;
-One container of Arrid extra dry labeled, Call poison control if ingested; and
-One container of Right guard sport unscented labeled, Call poison control if ingested.
-Two disposable razors.
Observation on 9/21/22 at 8:26 A.M., showed the C hallway shower room unlocked and unattended with two unlocked and unattended cabinets that contained:
-One container of Arrid extra dry labeled, Call poison control if ingested; and
-One container Right guard sport unscented labeled, Call poison control if ingested.
-Three disposable razors.
During an interview on 9/22/22 at 2:00 P.M., CNA C said the housekeeping staff is responsible for cleaning the shower rooms. He/She said they are cleaned daily and checked for hazardous or dangerous items. He/She said the shower aides should dispose of the razors, but housekeeping is also responsible for disposing of them if found while cleaning. He/She said the shower room door should be locked at all times when not in use. He/She said all staff are responsible to ensure the shower rooms are locked. He/She said razors and other sharp items should be locked up, and out of reach of residents. He/She said chemicals should not be in shower rooms, but locked up in the medication room. He/She would remove razors from a resident's room, who is receives an anticoagulant, and inform the charge nurse.
During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said staff are directed to lock the medication and treatment carts before they leave them. Both LPN A and LPN B said chemicals and other potential hazardous items such as razors or scissors should be kept in a locked cabinet at all times when not in use so confused residents don't have access to them, and don't get hurt.
During an interview on 9/22/22 at 2:32 P.M., CNA M said the shower aides should check the shower rooms throughout the day for razors, chemicals or any other potentially hazardous items. He/She said if razors or other sharps were left unattended, staff should put them in a sharps container. CNA M said the spa rooms should always be locked.
During an interview on 9/23/22 at 12:17 A.M., the DON said it is the shower aides responsibility to ensure the shower rooms are locked. He/ She would not expect razors, chemicals, or anything that could be hazardous to be left out because it puts the residents at risk for opening something up and ingesting it.
4. Review of the facility's Wheelchair Use Policy, dated 2006, showed staff are directed to lower the foot rests of the wheelchair, and place resident's feet on the foot rests if used. Position the resident's feet and legs in good body alignment.
5. Review of Resident #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/11/22, showed staff assessed the resident as:
-Severe cognitive impairment;
-Required extensive assistance from one staff member for locomotion on unit;
-Required total dependence assistance from one staff member for locomotion off unit;
-Used a wheelchair.
Observation on 9/20/22 at 8:57 A.M., showed CNA D propelled the resident from the dining room to midway down B Hall without foot pedals on the wheelchair. The resident's left foot touched the floor.
Observation on 9/20/22 at 9:01 A.M., showed CNA D propelled the resident down the hallway to his/her room without the use of foot pedals.
Observation on 9/21/22 at 8:41 A.M., showed CNA T propelled the resident from the dining area to his/her room with foot pedals, but did not ensure the resident's feet were on the pedals. The resident's feet were behind the pedals, and his/her feet dragged on the floor when he/she was propelled out of he dining room.
During an interview on 9/21/22 at 8:41 A.M., CNA T said he/she ensured the resident's feet were on the pedals before he/she propelled the resident. He/She didn't realize the resident's feet were not on the pedals and dragged on the floor. He/She said staff are directed to use foot pedals and ensure the resident's feet are on the foot pedals.
6. Review of Resident #30's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required assistance from on staff member for locomotion on and off unit;
-Used a wheelchair.
Observation on 9/21/22 at 8:16 A.M., showed the Business Office Manager (BOM) pulled the resident in a wheelchair from the dining room to the hallway without foot pedals. The resident's left toes dragged on the floor.
Observation on 9/21/22 at 8:30 A.M., showed CNA U propelled the resident in his/her wheelchair with the resident's hands on the wheels while he/she was propelled.
Observation on 9/19/22 at 1:46 P.M., showed Certified Medication Technician (CMT) V propelled the resident down the hallway to the dining room without foot pedals.
7. Review of Resident #57's admission MDS, dated [DATE] showed staff assessed the resident as:
-Cognitively Intact;
-Required assistance from on staff member for locomotion on and off unit;
-Used a wheelchair.
Observation on 9/19/22 at 1:38 P.M., showed CMT W propelled the resident from the dining room to the resident's room without the use of foot pedals.
8. Review of Resident #59's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required limited assistance from one staff member for locomotion on unit;
-Required extensive one person assistance from one staff member for locomotion off unit;
-Used a wheelchair.
Observation on 9/19/22 at 1:46 P.M., showed CMT V propelled the resident down the hall to the dining room without foot pedals.
Observation on 9/19/22 at 4:12 P.M., showed an unidentified staff member propelled the resident from the television room to the activity room without the use of foot pedals.
During an interview on 9/22/22 at 2:00 P.M., CNA C said staff are directed to make sure foot pedals are on and arms are inside the wheelchair. He/She had seen staff propel residents without foot pedals, but had not witnessed staff propel residents with their arms outside the chairs.
During an interview on 9/22/22 at 2:08 P.M., LPN A and LPN B said staff are directed to elevate the resident's feet on pedals and ensure the resident's arms on the armrest arms or inside the wheelchair prior to propelling them.
During an interview on 9/22/22 at 2:32 P.M., CNA M said staff are to ensure the resident has their arms inside the wheelchair and feet on the foot pedals before staff propel them. CNA M said if a resident refuses the foot pedals and wants to be propelled, staff should make sure the resident holds their feet up.
During an interview on 9/23/22 at 12:17 P.M., the DON said the staff are directed no pedals, no push. He/she said staff should keep the residents arms on the armrests or within the armrests. Injuries such as broken bones and skin breakdown could occur if feet and hands are not addressed during wheelchair locomotion.
NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, facility staff failed to ensure resident's personal information was protected when staff left residents' protected health information on top of the ...
Read full inspector narrative →
Based on observation, interview, and record review, facility staff failed to ensure resident's personal information was protected when staff left residents' protected health information on top of the medication cart and left the Electronic Health Record (EHR) open and unattended in public hallways. The facility census was 68.
1. Review of the facility's Quality of Life-Dignity Policy, revised August 2009, showed staff shall maintain an environment in which confidential clinical information is protected.
Review of the facility's Administration Procedures for All Medications Policy, dated 1/1/19, showed staff are directed to secure records containing protected health information.
Observation on 9/19/22 at 11:00 A.M., showed paper documentation on top of the computer cart, unattended on Hallway A with residents' information exposed. Further observation showed staff and residents walked past the cart.
Observation on 9/19/22 at 11:25 A.M., showed paper documentation on top of the computer cart, unattended on Hallway A with residents' information exposed. Further observation showed staff and residents walked past the cart.
Observation on 9/19/22 at 11:56 A.M., showed paper documentation on top of the computer cart, unattended on Hallway A with residents' information exposed. Further observation showed a resident's family member stood next to the cart.
Observation on 9/19/22 from 2:26 P.M. to 2:33 P.M., showed the EHR on top of the medication cart, unattended on Hallway C with residents' information exposed. Further observation showed staff and residents walked past the cart.
Observation on 9/20/22 8:34 A.M., showed the EHR on top of the medication cart, unattended in Hallway C with residents' information exposed. Further observation showed a family member walked by the cart.
Observation on 9/20/22 8:58 A.M., showed the EHR on top of the medication cart, unattended in Hallway C with residents' information exposed. Further observation showed staff and residents walked past the cart.
Observation on 9/20/22 9:06 A.M., showed the EHR on top of the medication cart, unattended in Hallway C with residents' information exposed. Further observation showed two residents passed by the cart.
During an interview on 9/22/22 at 2:00 P.M., Certified Nurse Aide (CNA) C said staff are directed to exit out of the computer system and close the computer. He/She said if the resident's personal information is on paper, then the paper should be covered, or flipped over so the information is not exposed. If he/she noticed an unattended computer screen with resident information visible to the public, he/she would minimize the screen and inform the nurse or Certified Medication Technician (CMT).
During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said staff are expected to lock the computer screens before they leave the medication carts and treatment cart to keep resident information from being exposed.
During an interview on 9/22/22 at 2:32 P.M., CNA M said staff are to ensure the computers screens are closed before they leave them to protect the residents medical information. He/She said if one was not closed he/she would notify the staff member responsible.
During an interview on 9/23/22 at 12:17 P.M., the Director of Nursing said he/she expects staff to lower the computer screens and close the narcotic count books before they leave the medication cart so resident information is not exposed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to complete an admission and a Significant Change Minimum Data S...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to complete an admission and a Significant Change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, within the timeframes directed by the Centers for Medicaid and Medicare Services (CMS) for two residents (Residents #7 and #65). The facility census was 68.
1. Review of the CMS, Long-Term Care (LTC) Facility, Resident Assessment Instrument (RAI) User's Manual, dated October 1, 2019, provides the following instruction for LTC staff. The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day one.
Review of Resident #65's admission MDS, dated [DATE], showed as of 9/22/22 the MDS had not been finalized or accepted.
2. Review of Centers for Medicare & Medicaid Services (CMS), Long-Term Care (LTC) Facility, Resident Assessment Instrument (RAI) User's Manual, dated October 1, 2019, provides the following guidance for LTC facility staff. The Significant Change MDS completion date must be no later than 14 days from the Assessment Reference Date (ARD), the specific end point of look-back periods in the MDS assessment process, no later than 14 days after the determination that the criteria for an significant Change were met.
Review of Resident #7's Significant Change MDS, dated [DATE], showed as of 9/22/22 the MDS had not been finalized or accepted.
During an interview on 9/23/22 at 12:17 P.M., the Director of Nursing said normally the MDS Coordinator is responsible to complete the MDS Assessments. He/she said the facility currently does not have the position filled and the assessments are completed by him/her and/or the regional team using a calendar to schedule the assessments. He/she said MDS assessments should be transmitted and locked in 14 days and/or according to the RAI manual.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 staff failed to complete and implement a baseline care plan within 48 hours o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to complete and implement a baseline care plan within 48 hours of admission and failed to document the baseline care plan was reviewed with the resident or responsible party for three residents (Residents #25, #66, and #88). The facility census was 68.
1. Review of the facility's Nursing Services policy, dated February 2022, showed:
-A baseline care plan is developed to address the immediate needs of the patient within 48 hours of the patient's admission;
-A summary of the baseline care plan will be shared with the patient and the representative.
2. Review of Resident #25's Annual Minimum Data Set, (MDS), a federally mandated assessment tool, dated 3/22/22, showed staff assessed the resident as:
-admitted on [DATE];
-Required supervision of one staff member for bed mobility, transfers, locomotion, eating, and toilet use;
-Occasionally incontinent of bladder;
-Had falls prior to admission;
-Was at risk for pressure ulcers;
-Received anticoagulants (medication's to prevent or reduce clotting of blood) seven out of seven days and diuretics (medication's to increase urine production) seven out of seven days, during the last seven days or since admission/entry if less than seven days.
Review of the resident's 48 hour baseline care plan, dated 4/1/21, showed staff did not complete a baseline care plan.
3. Review of Resident #66's Entry MDS, dated [DATE], showed staff documented the resident was admitted on [DATE].
Review of the resident's medical record showed staff did not develop and implement a baseline care plan for the resident within 48 hours of admission.
4. Review of Resident #88's admission MDS, dated [DATE], showed staff assessed the resident as:
-admitted [DATE];
-Severe Cognitive impairment;
-Diagnoses included dementia (symptoms that affect memory, thinking and interferes with daily life), urinary tract infection and atrial fibrillation (irregular heartbeat);
-Intermittent catheterization;
-Incontinent of bowel.
Review of the resident's medical record showed staff did not develop and implement a baseline care plan for the resident within 48 hours of admission.
5. During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said baseline care plans should be completed on admission by the admitting nurse. They said the care plan should be documented on paper, and should include how much assistance the resident needs, if they wear glasses, use oxygen or their level of care. Both LPN A and LPN B said it is a snapshot of the resident's care and they didn't know why one would not be completed for every resident.
During an interview on 9/23/22 at 12:17 P.M., the Director of Nursing said the baseline care plans are documented on paper by the admitting nurse within the first 24 hours after the resident's admission, and should cover information gathered such as code status, allergies, medications that would need monitoring, personal likes/dislikes, or anything picked up during the admission process. He/she said it is the basics until the full care plan can be developed by the MDS Coordinator. He/She said the baseline care plan was not completed or reviewed with the resident and/or resident's representative for residents #25 and #88.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5%, when staff administered medications late to one resident (Resident #26) and...
Read full inspector narrative →
Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5%, when staff administered medications late to one resident (Resident #26) and failed to prime an insulin pen before administration for one resident (Resident #15). Out of 25 opportunities observed, six errors occurred, resulting in a 24% error rate. The facility census was 68.
1. Review of the facility's Medication Error Report Form, undated, identified incorrect time and incorrect dose as a type of medication error.
2. Review of Resident #26's Physician's Order Sheet (POS), dated 8/22/22, showed staff were directed to administer the following medications at 7:00 A.M.:
-Levetiacetam (used to treat seizures) 500 Milligrams (mg), one tablet (tab) orally;
-Senna Plus (used to treat constipation) 50/8.6 mg, two tabs orally;
-Amlodipine (used to treat high blood pressure) 5 mg, one tab orally;
-Pregabalin (used to treat seizures) 75 mg, one capsule orally;
-Tramadol (used to relieve pain) 50 mg, one tab orally.
Observation on 9/21/22 at 8:42 A.M., showed Certified Medication Technician (CMT) N administered the following medications to the resident:
-Levetiacetam 500 mg, one tab orally;
-Senna Plus 50/8.6 mg, two tabs orally;
-Amlodipine 5 mg, one tab orally;
-Pregabalin 75 mg, one capsule orally;
-Tramadol to 50 mg, one tab orally.
The CMT administered the medications 1 hour and 42 minutes after the scheduled administration time.
Further observation, showed the CMT's computer identified the administration as late. The CMT clicked the note off the screen and did not notify anyone of the late administration.
During an interview on 9/21/22 03:03 PM, CMT N said administering medications at the wrong time is considered a medication error. The CMT said they administered the resident's medications late, and they were medication errors. He/She said he/she notified Registered Nurse (RN) O of the errors.
During an interview on 9/21/22 at 3:08 P.M., RN O said administering medication at the wrong time is a medication error. The RN said a medication error had not been reported to him/her today.
3. Review of the facility's Insulin Pen Education, dated 10/29/2019, showed staff are instructed to get the air out of the needle, point needle up in the air, dial one to two units and press the plunger with the thumb. Then dial in the dose of insulin to be administered.
Review of Resident #15's POS, dated 8/22/22, showed staff were directed to administer Novolog Flexpen U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/milliliter (mL) (3mL); 20 units; subcutaneous; three times a day.
Observation on 9/21/22 at 11:51 A.M., showed Licensed Practical Nurse (LPN) A pulled the resident's Novolog Flexpen insulin pen from the medication cart, dialed 20 units on the pen and administered the insulin, without first priming the insulin pen.
During an interview on 9/21/22 at 11:55 A.M., the LPN said he/she didn't know insulin pens had to be primed.
During an interview on 9/21/22 at 3:08 P.M., RN O said staff are expected to prime the insulin pen, before they dial the pen to the ordered units. The RN said if staff did not prime the pen, the resident did not get the ordered dose of insulin and it would be a medication error. The RN said staff had not reported any medication errors to him/her.
During an interview on 9/21/22 at 12:49 P.M., the Director of Nursing (DON) said wrong resident, wrong dosage, late on giving the medication, gave it to early are all medication errors. The DON said no one had notified him/her of any medication errors today. The DON said he/she would expect staff to notify the nurse, if the staff had a medication error.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interview and record review, facility staff failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the g...
Read full inspector narrative →
Based on interview and record review, facility staff failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances; failed to establish a grievance policy that identified a current grievance official, included the right to file a grievance anonymously and that required the facility to maintain evidence demonstrating the result of all grievances for a period of no less than three years; and failed to educate and review guidelines on how to file a grievance with the residents. The facility census was 68.
1. Review of the facility's Resident Rights Grievance Procedure, dated 2009, showed:
If at any time you are not being treated fairly, or if you feel that an employee has mistreated you in any way, please take the following steps:
-Notify the social worker for assistance in resolving the problem. The social worker serves as the center's in-house ombudsman. An ombudsman investigates complaints on behalf of the administrator and reports findings/resolution to the administrator;
-If you are not satisfied, notify the director of nursing;
-Should you remain unsatisfied, please take the concern to the assistant administrator or administrator;
-You are welcome to present the problem verbally or in writing. You may expect a response at each level as quickly as possible, certainly within 5 working days.
Review of the current staffing list, showed the list did not include a social worker.
Review of the facility's policies, showed the facility did not have a grievance policy.
Review of the facility records, showed the facility did not have a record of past grievance results.
Review of the Resident Council minutes, dated July 7, 2022, showed the resident council stated, We would like the menus back so we can fill them out. Further review showed the facility did not document a response.
Review of the Resident Council minutes, dated August 4, 2022 showed the resident council stated, They want the menus back so they can fill them out and choose what they want. Further review showed the facility did not document a response.
Review of the Resident Council minutes, dated September 1, 2022, showed the resident council stated, Residents also requesting a menu at meal time to decide what they want for the next day's meals. Further review showed the facility did not document a response.
During an interview on 9/21/22 at 11:34 A.M., Resident #24 said when the resident council met and made recommendations, residents never hear back. If residents make an individual complaint they never hear back. He/She said the menu issue had not been resolved.
During an interview on 9/21/22 at 11:43 A.M., Resident #26 said when the resident council discussed problems regarding the facility, the facility never responded to the requests, never made changes, and did not let residents know if any decision was made. The resident said no formal grievance policy was presented to the residents and he/she did not know if there was a formal procedure. He/She said the menu issue was one example that never was resolved.
During an interview on 9/22/22 at 2:00 P.M., Certified Nurse Aide (CNA) C said residents can discuss concerns or suggestions with the administrator during resident council meetings or report to the aides. He/She did not know what the process once a concern or suggestion is made by a resident. He/She said he/she did not know if concerns or suggestions were documented anywhere.
During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said when residents report issues or complaints, they inform the nurse and then the nurse tells management. Both LPN A and LPN B said there should be a follow up with the resident but are not sure who is doing that.
During an interview on 9/23/22 at 12:17 P.M., the Director of Nursing (DON) said when a resident has a concern or grievance it is reported to the social service director who then passes the information to the department head. He/she said the department head is responsible to investigate the issue and report it to the administrator. The DON said residents are informed of the outcomes during resident council and is not sure who is ultimately responsible for the process. He/She said the facility did not maintain records of grievances or how grievances were addressed. He/She said menus had been started briefly but not continued due to inexperienced and/or fill-in staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to accurately identify care areas for 10 residents (Re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to accurately identify care areas for 10 residents (Residents #6, #7, #14, #29, #35, #42, #58, #59, #60, and #65) in the resident's comprehensive care plans (CP). The facility census was 68.
1. Review of the facility's Patient Care policies, dated 2022 showed:
-Patients are assessed initially and at regular intervals using a Federal/State specified, standardized, comprehensive resident assessment instrument to identify functional capacity and health status;
-The process involves the entire Interdisciplinary Team (IDT);
-Decision making/planning is based on identified needs/problems and builds on patients strengths while taking into account the patients preferences;
-The care plan serves a guide for care decisions and is made available to use by all patient care personnel.
2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/9/22, showed staff assessed the resident as:
- Severe cognitive impairment;
- Required limited assistance from one staff member for dressing;
- Required extensive assistance from one staff member for personal hygiene;
- Did use antipsychotic medications for seven out of seven days;
- Did not receive hospice care;
- Diagnosis of dementia (disease affecting memory, thinking and interferes with daily life);
- Did not reject care.
Review of the Physician Order Summary (POS), undated, showed a diagnosis of unspecified dementia with behavioral disturbance. Further review showed an order for a 2 milligram Haloperidol tablet.
Observation on 9/20/22 at 10:22 A.M., showed the resident had long nails, unkempt facial hair, and wore the same shirt and pants as on 9/19/22.
Observation on 9/21/22 at 8:49 A.M., showed the resident had long nails, unkempt facial hair, and wore the same shirt and pants, covered in debris, as on 9/19/22.
Observation on 9/22/22 at 10:22 A.M., showed the resident had long, dirty nails, and unkempt facial hair.
Review of the resident's care plan, revised 9/6/22, showed it did not contain direction for staff in regard to the resident's facial hair and nail preferences, dementia care, or use of a psychotropic medication.
3. Review of Resident #7's admission Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows:
-admitted on [DATE];
-Cognitively impaired;
-Diagnoses included Heart Failure (failure of heart to pump adequately), Renal Insufficiency (decreased kidney function), Diabetes (insufficient production of insulin) and Dementia.
Review of the census line listing/tab in the medical record showed the resident was admitted to hospice on 7/22/22.
Review of the care plan dated 8/22/22, showed it did not contain the addition of hospice services.
4. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
- Severe cognitive impairment;
- Required extensive assistance from one staff member for dressing;
- Required limited assistance from one staff member for personal hygiene;
- Did not reject care.
Observation on 9/19/22 at 1:01 P.M., showed the resident had hair on his/her chin.
Observation on 9/21/22 at 3:19 P.M., showed the resident had hair on his/her chin.
Observation on 9/22/22 at 11:44 A.M., showed the resident had hair on his/her chin and wore the same sweater as on 9/21/22.
Review of the resident's care plan, revised 6/17/22, showed it did not contain direction for staff in regard to the resident's facial hair preferences.
5. Review of Resident #29's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
- Moderate cognitive impairment;
- Required assistance from on staff member for dressing;
- Required assistance from one staff member for personal hygiene.
- Did not reject care.
Observation on 9/20/22 at 8:46 A.M., showed the resident had hair on his/her chin.
Observation on 9/21/22 at 4:11 P.M., showed the resident had hair on his/her chin and long toe nails.
Observation on 9/22/22 at 11:36 A.M., showed the resident had hair on his/her chin.
Review the care plan, revised 7/25/22, showed it did not contain direction for staff in regard to the resident's facial hair preferences.
During an interview on 9/21/22 at 4:11 P.M., the resident and his/her daughter said he/she did have a shower on 9/20/22, but staff did not offer to trim or shave his/her facial hair. The resident's family member said he/she sometimes used a pair of tweezers to remove the facial hair. The resident said his/her toe nails are long and he/she did ask the staff to trim the nails, but was told they would during the next shower.
6. Review of Resident #35's admission MDS, dated [DATE], please correct the date showed staff assessed the resident as:
-Severe cognitive impairment;
-Required extensive assistance from two staff members for transfers and toileting;
-Required limited assistance from one staff member for personal hygiene;
-Had an indwelling urinary catheter;
-Received hospice care;
-Did not reject care;
-Received opioid and antianxiety medication;
-Had eye disease;
-Had diagnoses of cancer and diabetes.
Review of the resident's POS, showed orders on 6/27/22 for morphine (an opiate medication used to treat pain and is highly addictive), a hospice consult, bed rails for mobility, and scheduled pain screening; an order on 6/29/22 for catheter care; an order on 6/30/22 for trazodone (an antidepressant and sedative), and an order on 9/7/22 for lorazepam (a sedative used to treat seizure disorders, and to relieve anxiety).
Review of the nursing progress notes, from 6/29/22 through 8/25/22, showed staff documented:
-Hospice Care;
-The resident requesting antianxiety medication;
-Suicidal ideation
Review of the resident's care plan, dated 7/7/22, showed it did not contain direction for staff to address the cancer diagnosis, cognitive impairment, behavior or mood assessments, assistance needed for mobility, catheter care, diabetic care, hospice care, use of bed rails, dietary needs, or use of opioid and antianxiety medication.
7. Review of Resident #42's POS, start date 4/12/22, showed an order for hospice to provide services.
Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
- Severe cognitive impairment;
- Required limited assistance from two staff members for dressing;
- Required setup assistance from staff members for personal hygiene;
- Did not receive hospice care;
- Did reject care one of three days.
Review of nurse progress notes, from 8/1/22 through 9/9/22, showed staff documented communication with the hospice provider.
Observation on 9/20/22 at 10:36 A.M., showed the resident had long nails and his/her facial hair was unkempt.
Observation on 9/21/22 at 8:15 A.M., showed the resident had long, dirty nails, and his/her facial hair was unkempt.
Observation on 9/22/22 at 10:58 A.M., showed the resident wearing the same clothing as 9/21/22, with debris on his/her pants, and had long, dirty nails, and his/her facial hair was unkempt.
Review of the resident's care plan, revised 8/22/22, showed it did not contain direction for staff in regard to the resident's facial hair preferences and hospice care.
8. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-Severely impaired cognition;
-Required total, two person assistance with bed mobility, dressing and toilet use;
-Required total, one person assistance with bathing and hygiene;
-Impairments to both sides of upper and lower extremities.
-Diagnosis of Dementia, Cerebrovascular accident (stroke- the loss of blood flow to the brain) and Hemiplegia (paralysis of one side of the body).
Review of the resident's care plan, revised 9/6/22, showed staff documented the resident used 1/4 rails as a positional/care aid and directed them to provide prompting as needed for use during repositioning and Activities of Daily Living (ADL) cares.
During an interview on 9/21/22 at 2:48 P.M., the Director of Nursing (DON) said in his/her clinical assessment, he/she does not believe the resident needs bed rails. The DON said a year ago the resident could use them to reposition himself/herself in bed, but not now.
9. Review of Resident #59's Annual MDS, dated [DATE], showed staff assessed the resident as:
- Cognitively intact;
- Required limited assistance from one staff member for dressing and personal hygiene;
- Did not reject care.
Observation on 9/19/22 at 1:57 P.M., showed the resident had hair on his/her upper lip and chin.
Observation on 9/20/22 at 8:40 A.M., showed the resident had hair on his/her upper lip and chin.
Observation on 9/21/22 at 2:08 P.M., showed the resident had hair on his/her upper lip and chin.
Observation on 9/22/22 at 3:41 P.M., showed the resident had hair on his/her upper lip and chin.
Review of the resident's care plan, revised 9/6/22, showed it did not contain direction for staff in regard to the resident's facial hair preferences.
10. Review of Resident #60's Annual MDS dated [DATE], showed staff assessed the resident as:
-Mildly cognitively impaired;
-Diagnosis included Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, and Anxiety;
-No oxygen use.
Observation on 9/19/22 at 11:14 A.M., showed the resident in bed with oxygen on via nasal cannula.
Observation on 9/20/22 at 8:14 A.M., showed the resident in bed with oxygen on via nasal cannula.
Observation on 9/21/22 at 8:22 A.M., showed the resident in bed with oxygen on via nasal cannula.
Review of the resident's care plan dated 9/6/22, showed it did not contain direction for oxygen use.
11. Review of Resident #65 medical record, showed the staff did not completed the required MDS Assessment.
Review of the resident's POS, undated, showed an order for a 15 milligram Xarelto (a blood thinner) tablet taken once a day.
Observation on 9/19/22 at 12:51 P.M., showed the resident had hair on his/her chin and long toe nails.
Observation on 9/20/22 at 3:17 P.M., showed the resident had hair on his/her chin.
Observation on 9/21/22 at 3:26 P.M., showed the resident had hair on his/her chin and wore the same shirt and pants as on 9/20/22.
Review of the resident's care plan, revised 9/8/22, showed it did not contain direction for staff in regard to the resident's facial hair and nail care preferences or use of an anticoagulant.
12. During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said the MDS nurse is responsible to update the Care Plans, but is not sure who the MDS nurse is or if the plans are being updated. Both LPN A and LPN B said the care plans should be updated monthly. LPN A and LPN B said he/she would expect to see any changes or directions regarding resident care such as diet, transfers, hospice, oxygen, medications, bed rail use, ADL preferences, falls, and code status in the care plans. Both LPN A and LPN B said changes to the care plan are reported to the staff by a memo given out or through daily report.
During an interview on 9/23/22 at 12:17 P.M., the DON said right now he/she and the regional team are completing and updating care plans. He/she said he/she is responsible to ensure they are completed and include falls, interventions, weight loss/gains, code status, side rails, allergies, medications, ADL preferences, hospice, and dementia. The DON said interventions are evaluated over time by the management team or Interdisciplinary Team (IDT) weekly making sure the goals are measurable. He/she said care plans should be updated with any changes and at least quarterly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility staff failed to meet professional standards of quality when sta...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility staff failed to meet professional standards of quality when staff failed to provide consistent documentation in regard to residents' Physician Orders for Life-Sustaining Treatment (designed to improve patient care by creating a medical order form that records residents' treatment wishes so staff know what treatments the resident wants in the event of a medical emergency) for three residents (Resident #9, #30 and #65). Additionally, facility staff failed to follow scope of practice by allowing a Certified Nurse Aide (CNA) to administer medication without an order to two residents (Residents #23 and #40). The facility census was 68.
1. Review of the facility's Emergency Procedure - Cardiopulmonary resuscitation (CPR) policy, undated, showed if a resident experiences a cardiac arrest, licensed staff must provide basic life support, including CPR, until the arrival of emergency medical services and in accordance with the resident advanced directives, or in the absence of advanced directive or a Do Not Resuscitate (DNR) Order.
Further review of the policy showed it did not contain direction on who is responsible to obtain the advanced directive information, when it is obtained, how it is obtained or how often it is reviewed.
2. Review of Resident #9's MDS, a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as cognitively impaired.
Review of the resident's face sheet showed staff documented the resident's code status (order for life sustaining treatment) as a DNR.
Review of the Physician Order Summary (POS), undated, showed it did not contain an order for the resident's code status.
3. Review of Resident #30's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact.
Review of the resident's face sheet showed staff documented the resident's code status as a DNR.
Review of the POS, undated, showed it did not contain an order for his/her code status.
4. Review of Resident #65's medical record, showed it did not contain a completed MDS Assessment.
Review of the care plan, revised [DATE], showed the resident's wishes were DNR.
Review of the POS, undated, showed the resident had an order of Full Code.
During an interview on [DATE] at 2:08 P.M., LPN A and LPN B said residents should have orders for their code status so the staff know what their wishes are. Both LPN A and LPN B said the admitting nurse is responsible to obtain the order, enter the orders and make sure they match the care plans.
During an interview on [DATE] at 12:17 P.M., the Director of Nursing (DON) said advanced directives are obtained by the social service department then orders are received by the admitting nurse. He/she said medical records then does a chart audit to ensure they are correct and match in the records.
5. Review of the facility's Medication Administration-General Guidelines Policy, revised [DATE], showed:
-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;
-Medications are prepared only by licenses nursing, medical pharmacy, or other personnel authorized by state laws and regulations to prepare and administer medications.
6. Observation on [DATE] at 8:18 A.M., showed CNA C applied Nystatin powder to the abdomen and groin folds of resident #23 after providing perineal care. He/she sprinkled the powder directly onto the skin from the container.
Review of Resident #23's POS, undated, showed it did not contain an order for Nystatin (used to treat yeast infection) Powder.
7. Observation on [DATE] at 4:02 P.M., showed LPN K left Nystatin powder in an unlabeled container in Resident #40's room on the bedside table. Observation showed the LPN instructed Nursing Assistant E (NA) and CNA D to apply the Nystatin powder after they performed perineal care on the resident. NA E applied Nystatin power to abdomen and groin folds. He/ She sprinkled the powder directly onto the skin from the container. NA E said the Nystatin powder was used for yeast.
Review of Resident #40's POS, dated [DATE] through [DATE], showed it did not contain an order for Nystatin powder.
During an interview on [DATE] at 4:26 P.M., CNA D said they apply Nystatin powder with every perineal care and during every care change. He/ She said sometimes the nurse applies it.
During an interview on [DATE] at 2:08 P.M., LPN A and LPN B said licensed nurses and medication technicians are the only ones who should pass medication. Both LPN A and LPN B said Nystatin is considered a medication and should not be administered by a CNA. LPN B said the powder is sprinkled onto a gloved hand then applied to the skin.
During an interview on [DATE] at 12:17 P.M., the DON said only the Medication Technicians and Nurses should apply or give medications. He/ She said anything that requires a prescription, including Nystatin powder, should not be administered by a CNA. He/ She said medication administration has to be done by a licensed or registered nurse because it is out of a CNA's scope of practice.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure residents that were unable to complete their ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure residents that were unable to complete their own activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene when staff failed to provide hair care and nail care to eight residents (Residents #6, #14, #25, #29, #42, #59, #62, and #65). The facility census was 68.
1. Review of the facility's Activity of Daily Living (ADL) policy, undated, showed:
-Resident self-image is maintained;
-Equipment and instruction for mouth care, shaving, makeup, and hair care are provided;
-Frequent showers or baths are scheduled and assistance provided when required.
Review of the facility's Quality of Life-Dignity policy, dated August, 2009, showed:
-Residents shall be treated with dignity and respect at all times;
-Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth;
-Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).
2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/9/22, showed staff assessed the resident as:
-Severe cognitive impairment;
-Required limited assistance from one staff member for dressing;
-Required extensive assistance from one staff member for personal hygiene;
-Did not reject care.
Review of the resident's care plan, revised 9/6/22, showed staff were directed to provide assistance to the resident to perform, improve, and maintain their ADLs. Further review showed staff were to ensure the resident wore clean clothes.
Observation on 9/20/22 at 10:22 A.M., showed the resident had long nails, unkempt facial hair, and wore the same shirt and pants as they did on 9/19/22.
Observation on 9/21/22 at 8:49 A.M., showed the resident had long nails, unkempt facial hair, and wore the same shirt and pants as they had on 9/19/22. The clothes were covered in debris.
Observation on 9/22/22 at 10:22 A.M., showed the resident had long, dirty nails, and unkempt facial hair.
3. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severe cognitive impairment;
-Required extensive assistance from one staff member for dressing;
-Required limited assistance from one staff member for personal hygiene;
-Did not reject care.
Review of the resident's care plan, revised 6/17/22, showed staff were directed to provide assistance to the resident to perform, improve, and maintain their ADLs. Further review showed staff were directed to anticipate the resident's ADL needs as he/she has become more confused and unaware of personal care needs.
Observation on 9/19/22 at 1:01 P.M., showed the resident had hair on his/her chin.
Observation on 9/21/22 at 3:19 P.M., showed the resident had hair on his/her chin.
Observation on 9/22/22 at 11:44 A.M., showed the resident had hair on his/her chin.
4. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively Intact;
-Required limited assistance of one staff member for bed mobility, dressing, transfers, and personal hygiene;
-Did not refuse care;
-Had diagnosis of hypertension (high blood pressure), dementia (loss of memory, language, and problem- solving abilities), and Parkinson's disease (progressive disorder that affects the nervous system and includes involuntary movements, like tremors).
Review of the resident's care plan, revised 6/2/22, showed staff were directed to provide assistance to the resident to perform, improve, and maintain their ADLs. Further review showed it did not contain direction for staff in regard to the resident's facial hair preferences.
Observation on 9/19/22 at 11:35, showed the resident with unkempt facial hair on his/her chin and cheeks.
Observation on 9/20/22 at 9:07 A.M., showed the resident with unkempt facial hair on his/her chin and cheeks.
During an interview on 9/20/22 at 9:07 A.M., the resident said he/she would like to be shaved every day, but only gets shaved on Mondays and Thursdays. He/she said it bothers him/her to not be shaved.
5. Review of Resident #29's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Moderate cognitive impairment;
-Required assistance from one staff member dressing;
-Required assistance from one staff member for personal hygiene.
-Did not reject care.
Review of the resident's care plan, revised 7/25/22, showed staff are directed to provide assistance to the resident to perform, improve, and maintain their ADLs.
Observation on 9/20/22 at 8:46 A.M., showed the resident had hair on his/her chin.
Observation on 9/21/22 at 4:11 P.M., showed the resident had hair on his/her chin and long toe nails.
Observation on 9/22/22 at 11:36 A.M., showed the resident had hair on his/her chin.
During an interview on 9/21/22 at 4:11 P.M., the resident and his/her family member said he/she had a shower on 9/20/22, but staff did not trim or shave his/her facial hair. The resident's family member said he/she had to bring tweezers into the facility to take care of the resident's facial hair himself/herself. The resident said his/her toe nails are long and he/she asked staff to trim them, but they had not.
6. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severe cognitive impairment;
-Required limited assistance from two staff members for dressing;
-Required setup assistance from staff members for personal hygiene.
-Rejected care one of three days.
Review of the resident's care plan, revised 8/22/22, showed it did not contain direction for staff in regard to the resident's facial hair, nails, and clothing. Additionally, it did not contain direction for staff in regard to resident refusal of care.
Observation on 9/20/22 at 10:36 A.M., showed the resident had long nails and unkempt facial hair.
Observation on 9/21/22 at 8:15 A.M., showed the resident had long, dirty nails, and unkempt facial hair.
Observation on 9/22/22 at 10:58 A.M., showed the resident wore the same clothes as he/she did on 9/21/22, with debris on the pants. Further observation showed he/she had long, dirty nails, and unkempt facial hair.
7. Review of Resident #59's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required limited assistance from one staff member for dressing and personal hygiene;
-Did not reject care.
Review of the resident's care plan, revised 9/6/22, showed staff were directed to assist the resident with hygiene. Further review showed staff the resident was legally blind.
Observation on 9/19/22 at 1:57 P.M., showed the resident had hair on his/her upper lip and chin.
Observation on 9/20/22 at 8:40 A.M., showed the resident had hair on his/her upper lip and chin.
Observation on 9/21/22 at 2:08 P.M., showed the resident had hair on his/her upper lip and chin.
Observation on 9/22/22 at 3:41 P.M., showed the resident had hair on his/her upper lip and chin.
During an interview on 9/20/22 at 8:40 A.M., the resident said he/she takes care of her own facial hair. He/She said staff have offered to shave him/her, but does not want them to out of fear of growing a mustache, due to using a razor. He/She said staff have not offered him/her an alternative way to remove his/her facial hair, and it bothers him/her when he/she feels facial hair. He/She said he/she is visually impaired and not able to see straight forward, but able to see peripherally.
8. Review of Resident #62's Quarterly MDS, dated [DATE], showed the staff assessed the resident as:
-Cognitively Impaired;
-Required limited assistance of one staff member on dressing and personal hygiene;
-Did not refuse care;
-Had diagnoses of dementia (loss of memory, language, and problem- solving abilities), and Parkinson's disease (progressive disorder that affects the nervous system and includes involuntary movements, like tremors).
Review of the resident's care plan, revised 9/7/22, showed staff were directed to provide assistance to the resident to perform, improve, and maintain their ADLs. Further review showed staff were directed to wash the resident's face, shave him/her with an electric razor, and dry his/her face every other morning.
Observation on 9/19/22 at 10:44 A.M., showed the resident had a care sign above his/her bed that read,Shave every day.
Observation on 9/20/22 at 9:43 A.M., showed the resident had unkempt facial hair on his/her upper lip and cheeks.
9. Review of Resident #65 medical record, showed it did not contain a completed MDS Assessment.
Review of the resident's care plan, revised 9/8/22, showed staff were directed to provide assistance to the resident to perform, improve, and maintain their ADLs.
Observation on 9/19/22 at 12:51 P.M., showed the resident had hair on his/her chin and long toe nails.
Observation on 9/20/22 at 3:17 P.M., showed the resident had hair on his/her chin.
Observation on 9/21/22 at 12:05 P.M., showed the resident had hair on his/her chin.
10. During an interview on 9/22/22 at 2:00 P.M., Certified Nurse Aide (CNA) C said the shower aides are responsible for shaving the residents and trimming their nails on shower days. He/She said the aides can trim the residents nails and shave the residents if needed. He/She had not noticed residents wearing the same clothes for multiple days, and had not noticed any residents with unkempt facial hair or long nails. He/She had previously noticed resident #6 wearing the same clothes multiple days in a row. He/She said the resident's clothes should be changed daily or more often if they are dirty. He/She said if a resident refused care the charge nurse should be notified.
During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said all nursing staff are responsible for making sure residents are clean, dry and comfortable. LPN A said he/she is not sure how often nails are trimmed and residents are shaved, but thought it was twice a week. Both LPN A and LPN B said they felt there was enough staff to ensure nail care and shaving was completed in a timely manner, so they did not know why it was not done. They said they did not feel there was an issue with facial hair, nail care or resident clothing not being changed.
During an interview on 9/23/22 at 1:52 P.M., the Director of Nursing said he/she expects the shower aides to ask the residents if they want their facial hair shaved and nails trimmed with every shower. He/She expects the residents clothes to be changed daily. He/She said he/she noticed residents with facial hair and long nails. He/She said there are residents who refuse to change their clothes, but it should be documented by the charge nurse and noted in the care plan. He/She said staff are directed to tell the charge nurse if a resident refuses care and it should be documented on the shower sheet. He/She said he/she expects the charge to reproach the resident. Additionally, he/she said if staff see a resident with unwanted facial hair or long nails he/she would expect them to to address.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility staff failed to use alternatives prior to bed rail installation, asse...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility staff failed to use alternatives prior to bed rail installation, assess for risk of entrapment, or obtain informed consent for bed rails for eleven residents (Resident #6, #24, #25, #35, #41, #42, #47, #51, #52, #60, #62). The facility census was 68.
1. Review of the facility's Bed Safety policy, dated December 2007, showed:
-The resident's sleeping environment shall be assessed by the interdisciplinary team (IDT), considering the resident's safety, medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habit and bed environment;
-Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks;
-The facility's education and training activities will include instruction about risk factors for resident injury due to beds and strategies for reducing risk factors for injury, including entrapment;
-If side rails are used, there shall be an IDT assessment of the resident, consultation with the Physician, and input from the resident and/or legal representative;
-Staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use;
-Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified;
-Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails;
-Further review showed the policy did not contain direction on how often the assessment or consultation with the physician will occur.
2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/9/22, showed staff assessed the resident as:
- Severe cognitive impairment;
- Required no assistance from staff members for bed mobility or transfers
- Did not use bed rails.
Review of the resident's bedrail consent form, dated 4/27/22, showed the resident did not use side rails.
Observation on 9/20/22 at 10:23 A.M., showed the resident in bed with a raised bed rail on one side of the bed.
Observation on 9/21/22 at 8:18 AM., showed a bed rail raised on one side of the resident's bed.
Observation on 9/22/22 at 3:42 PM., showed the resident in bed with a raised bed rail on one side of the bed.
Further review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Review of the resident's care plan, revised 9/6/22, showed it did not contain direction for staff in regard to bed rails.
3. Review of Resident #24's Annual MDS, dated [DATE], showed staff assessed the resident as:
- Cognitively intact;
- Required limited assistance from staff for bed mobility and was totally dependent on two staff for transfers;
- Did not use bed rails.
Review of the resident's medical record showed a side rail consent form dated 4/18/22 with verbal consent of the resident's family member due to resident confusion. Further review showed the consent did not contain risks or benefit information or alternatives to bed rail use.
Further review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Observation on 9/2/22 at 11:22 A.M., showed the resident in bed with a raised bed rail on the right side of the bed.
4. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required limited assistance of one staff member for bed mobility and transfers;
-Did not use bed rails.
Review of the resident's medical record showed a side rail consent form dated 4/17/22 with verbal consent of the resident's spouse due to resident confusion. Further review showed the consent did not contain risks or benefit information or alternatives to bed rail use.
Further review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Observation on 9/19/22 at 11:35 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/19/22 at 2:19 P.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/20/22 at 8:55 A.M., the bed with side rails on both sides of the bed
During an interview on 9/20/22 at 9:17 A.M., the resident said the bed rails helped stop him/her from rolling. He/She said the bedrails did not help him/her any and he/she used them occasionally to help himself/ herself roll over.
5. Review of Resident #35's admission MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Required extensive assistance from two staff for bed mobility and transfers;
-Did not use bed rails.
Observation on 9/19/22 at 11:01 A.M., showed the resident in bed with a raised left bed rail.
Observation on 9/20/22 at 8:34 A.M., showed the resident in bed with a raised left bed rail.
During an interview on 9/19/22 at 11:01 A.M., the resident said he did not know why he had a bed rail, and did not think he/she used it.
Review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Review of the resident's care plan, dated 6/27/22, showed it did not contain direction for staff in regard to bed rails.
6. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Independent for bed mobility and required supervision from staff for transfers;
-Did not use bed rails.
Review of the resident's medical record showed a side rail consent form dated 4/27/22 with verbal consent of the resident's spouse due to resident confusion. Further review showed the consent did not contain risks or benefit information or alternatives to bed rail use.
Further review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Observation on 9/19/22 at 11:09 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/20/22 at 9:06 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
7. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
- Severely cognitively impaired;
- Independent with bed mobility and required limited assistance of two staff for transfers;
- Did not use bed rails.
Observation on 9/20/22 at 10:38 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/21/22 at 8:16 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/22/22 at 3:41 P.M., showed raised bed rails on both sides of the bed.
Review of the resident's medical records showed staff did not document an alternative was attempted prior to the use of bed rails.
Further review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Review of the resident's POS, undated, showed it did not contain documentation of an order for side rail use.
8. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required limited assistance of one staff member for bed mobility and transfers;
-Did not use bed rails.
Review of the resident's medical record showed a side rail consent form dated 5/4/22 with verbal consent of the resident's family member due to resident confusion. Further review showed the consent did not contain risks or benefit information or alternatives to bed rail use.
Further review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Observation on 9/19/22 at 11:01 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/20/22 at 8:16 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/21/22 at 8:17 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
9. Review of Resident #51's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Independent for bed mobility and required supervision for transfers;
-Did not use bed rails.
Review of the resident's medical record showed a side rail a consent form dated 4/27/22 signed by the resident which showed the resident did not use side rails.
Review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Review of the resident's care plan, dated 3/4/22, showed it did not contain direction for staff in regard to bed rails.
Observation on 9/19/22 at 11:16 A.M., showed raised bed rails on both sides of the bed.
Observation on 9/21/22 at 11:16 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
During an interview on 9/21/22 at 11:16 A.M., the resident said he/she uses side rails on the bed for mobility.
10. Review of Resident #52's Quarterly MDS, dated [DATE] showed staff assessed the resident as:
-Cognitively intact;
-Independent with bed mobility and transfers.
-Did not use bed rails.
Review of the resident's medical record showed a side rail consent dated 5/23/22 signed by the residents' family member due to resident confusion. Further review showed the consent did not contain risks or benefit information or alternatives to bed rail use.
Observation on 9/19/22 at 12:02 P.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/20/22 at 8:31 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/21/22 at 8:39 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
During an interview on 9/20/22 at 8:31 A.M., the resident said he/she uses the side rails to keep the call light in an area he/she could reach it and how he/she keeps himself centered in the bed.
11. Review of Resident #60's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Required physical assistance of two staff for bed mobility and transfers.
-Did not use bed rails.
Review of the resident's medical record showed a side rail consent dated 4/18/22 signed by the residents' family member due to resident confusion. Further review showed the consent did not contain risks or benefit information or alternatives to bed rail use.
Observation on 9/19/22 at 11:14 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/20/22 at 8:14 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/21/22 at 8:22 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
11. Review of Resident #62's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitive status not identified, previously mild cognitively impaired;
-Required set up only for bed mobility and transfers;
-Did not use bed rails.
Review of the resident's medical record showed a side rail consent dated 4/20/22 signed by the residents' family member due to resident confusion. Further review showed the consent did not contain risks or benefit information or alternatives to bed rail use.
Review of the resident's medical records showed staff did not complete a bed rail safety check for all possible entrapment zones and did not document regular inspections of the bed rails.
Observation on 9/19/22 at 10:44 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/20/22 at 1:25 P.M. showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/21/22 at 8:16 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/21/22 at 8:59 A.M., showed the resident in bed with raised bed rails on both sides of the bed.
Observation on 9/21/22 at 1:19 P.M., showed the resident in bed with raised bed rails on both sides of the bed.
12. During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said residents get bed rail assessments when they are admitted by the admitting nurse. Both LPN A and LPN B did not know how often they were completed after that.
During an interview on 9/23/22 at 1:51 P.M., the Director of Nursing (DON) said a resident gets asked about bed rails upon admission. Then, the staff gets an order from the doctor and maintenance does a side rail assessment to ensure the resident is not at risk for entrapment. He/ She does not know how often side rail assessments are done, but said the assessments should be done quarterly. He/She said the MDS Nurse is responsible for the annual and quarterly assessments. He/She said if the resident cannot give consent, then the family gives consent. He/She said the side rails should be in the care plans.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, facility staff failed to conduct regular inspections of bedrails as part of a regular maintenance program by failing to measure and assess all possi...
Read full inspector narrative →
Based on observation, interview, and record review, facility staff failed to conduct regular inspections of bedrails as part of a regular maintenance program by failing to measure and assess all possible entrapment zones for 12 residents (Residents #6, #24, #25, #35, #37, #40, #41, #42, #47, #48, #52, and #62). The facility census was 68.
1. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement.
Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013 identifies seven different potential, zones of entrapment. This guidance characterizes the head, neck, and chest as key body parts that are at risk of entrapment.
Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts shows the potential risk of bed rails may include:
-Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress;
-More serious injuries from falls when patient climb over rails;
-Skin bruising, cuts and scrapes;
-Inducing agitated behavior when bed rails are used as a restraint;
-Feeling isolated or unnecessarily restricted;
-And preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom, or retrieving something from a closet.
2. Review of the facility's Bed Safety Policy, revised December of 2007, showed the policy instructed staff to try to prevent death/injuries from the bed and related equipment, including the frame, mattress, side rails, headboard, footboard and bed accessories. Review showed the facility shall provide the following approaches:
-Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risk;
-Review that gaps within the bed system are within the dimensions established by the FDA;
-The maintenance department shall provide a copy of inspections to the administrator (AD) and report results to the Quality Assurance (QA) Committee for appropriate action
Review of the facility's Bed Rail Safety Check Policy, dated April of 2009, showed each side rail had four zones to be measured. For quarter or half rails on both sides of the bed, there would be eight zones, which required measurements.
3. Review of Resident #6's Physician Order Summary (POS), dated 11/24/20, showed an order for a side rail for positioning and body mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/20/22 at 10:23 A.M., showed the resident in bed with a raised bedrail on one side of the bed.
Observation on 9/21/22 at 8:18 AM., showed a raised bedrail on one side of the resident's bed.
Observation on 9/22/22 at 3:42 PM., showed the resident in bed with a raised bedrail on one side of the bed.
4. Review Resident #24's POS, dated 6/21/22 showed and order for a quarter siderail for positioning and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/20/22 at 9:15 A.M., P.M., showed the resident in bed with a quarter bedrail raised.
5. Review of Resident #25's POS, dated 4/1/21, showed an order for a quarter side rail for positioning and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/19/22 at 2:19 P.M., showed the resident in bed with a quarter bedrail raised.
Observation on 9/20/22 at 8:55 A.M., showed a quarter bedrail raised on the resident's bed.
6. Review of Resident #35's POS, dated 6/27/22, showed a physician order for a quarter side rail for positioning and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/20/22 at 8:34 A.M., showed the resident in bed, with a quarter bedrail raised.
7. Review of Resident #37's POS, dated 8/22/22, showed a physician order for a quarter side rail for positioning and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/19/22 at 3:04 P.M., showed the resident in bed with a quarter bedrail raised.
8. Review of Resident #40's POS, dated 8/22/22, showed a physician order for a quarter side rail for positioning and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/21/22 at 9:14 A.M., showed the resident in bed two quarter bedrail raised on both sides.
9. Review of Resident #41's POS, dated 4/21/22, showed a physician order for a quarter side rail for positioning and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/20/22 at 9:06 A.M., showed the resident in bed with a quarter bedrail raised.
10. Review of the Resident #42's POS, undated, showed it did not contain documentation of an order for side rail use.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/20/22 at 10:38 A.M., showed the resident in bed with a raised bedrail on both sides.
Observation on 9/21/22 at 8:16 A.M., showed the resident in bed with a raised bedrail on both sides.
Observation on 9/22/22 at 3:41 P.M., showed raised bed rails on both sides of the bed.
11. Review of Resident #47's POS, dated 2/12/19, showed an order for quarter side rails for positioning and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/19/22 at 11:01 A.M., showed the resident in bed with a quarter bedrail raised.
Observation on 9/20/22 at 8:16 A.M., showed the resident in bed with a quarter bedrail raised.
Observation on 9/21/22 at 8:17 A.M., showed the resident in bed with a quarter bedrail raised.
12. Review of Resident 48's POS, dated 8/22/22, showed an order for one side rail for position and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/19/22 at 3:25 P.M., showed the resident in his/her bed, with a quarter bedrail raised on the right side of the bed. The resident's left side of bed is against the wall.
13. Review of Resident #52's POS dated 2/3/19 showed a physician order for a quarter side rail for positioning and mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/19/22 at 12:02 P.M., showed the resident in bed with quarter bedrails raised on both sides of the bed.
Observation on 9/20/22 at 8:31 A.M., showed the resident in bed with quarter bedrails raised on both sides of the bed.
Observation on 9/21/22 at 8:39 A.M., showed the resident in bed with quarter bedrails raised on both sides of the bed.
14. Review of Resident #62's POS, dated 2/13/19, showed an order for quarter side rails for positioning and bed mobility.
Review of the resident's medical record showed it did not contain a bedrail safety check for all possible entrapment zones or documentation of regular inspections of the bedrails.
Observation on 9/19/22 at 10:44 A.M., showed the resident in bed with quarter bedrails raised on both sides of the bed.
Observation on 9/20/22 at 1:25 P.M., showed the resident in bed with quarter bedrails raised on both sides of the bed.
Observation on 9/21/22 at 8:16 A.M., showed loose quarter bedrails raised on both sides of the resident's bed.
Observation on 9/21/22 at 8:59 A.M., showed the resident in bed with loose bedrails raised on both sides of the bed.
Observation on 9/21/22 at 1:19 P.M., showed the resident in bed with bedrails raised on both sides of the bed.
15. During an interview on 9/27/22 at 3:09 P.M., the Maintenance Director said a lot of residents have two rails, so they measure both sides of the bed. They have a form they are directed to fill out with all eight zones listed, but he/she only measured two. He/She said when he/she started that was all staff were measuring.
During an interview on 9/28/22 at 8:45 A.M., the Director of Nursing said staff are expected to complete the bed rail safety form with the information it asks for. He/She said if there is information missing from the form that is required, then it had not been filled out correctly.
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, facility staff failed to allow sanitized dishes to air dry before stacking in storage and use to prevent cross-contamination and the growth of food-...
Read full inspector narrative →
Based on observation, interview, and record review, facility staff failed to allow sanitized dishes to air dry before stacking in storage and use to prevent cross-contamination and the growth of food-borne pathogens. Facility staff failed to perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff failed to store food in a manner to prevent contamination and out-dated use. Facility staff also failed to maintain the kitchen physical environment and equipment in a sanitary condition. The facility census was 68.
1. Review of the facility's Machine Warewashing policy, dated 11/2017, showed the policy directed staff to air dry all items and make sure all items are completely dry before stacking to prevent wet-nesting.
Observation on 09/19/22 at 9:54 A.M., showed dietary staff removed wet dishes from the clean side of the chemical dishwashing station and stacked them together on the storage shelves. Further observation showed 14 insulated dome plate covers, 19 insulated plate holders and 12 service trays stacked together wet on utility carts.
Observation on 09/19/22 at 10:30 A.M., showed the cook removed a metal food service pan from below the countertop. Observation showed water poured out of the pan as the cook turned it over. The inside of the pan was wet and the cook placed prepared diced chicken into the wet stacked pan. Observation also showed six additional metal food service pans stacked together wet on the shelf below the countertop.
Observation on 9/20/22 at 12:48 P.M., showed dietary aide (DA) BB stacked visibly wet plates in the plate warmer in the service area. Further observation showed [NAME] AA used the wet plates during resident lunch service.
Observation on 9/20/22 at 2:10 P.M., showed clean plates stacked inverted in a storage cart in the dishwashing area. Further observation showed multiple plates visibly wet.
During an interview on 9/21/22 at 11:59 A.M., the dietary manager (DM) said he is responsible to ensure the kitchen is operated according to regulations. He said it is expected the staff would allow the dishes to air dry before they put the dishes away or use them. The DM said the staff had received verbal training to avoid wet stacking the dishes.
During an interview on 9/21/22 at 1:22 P.M., the administrator said the DM is responsible to ensure the kitchen is operated according to regulations. He said the facility has a policy on air drying of dishes, and staff had been trained on the policy. The administrator said it is expected staff would allow the dishes to completely air dry before they put them away or use them.
2. Review of the facility's Handwashing policy, dated 11/2017, showed:
- The basic practice of handwashing is the single most important action that can be taken to prevent the spread of disease;
- Hands should be washed before starting to work; after break time; after using the restroom; after touching hair, face, or body; after eating, drinking, smoking, sneezing, coughing, or touching money; after leaving and returning to a food preparation area; before putting on and after removing gloves; after handling uncooked product; after cleaning or taking out the garbage,; touching clothing or apron; or after touching anything that might contaminate hands, such as dirty equipment, work surfaces, or towels;
- If working in dishroom, hands must be washed when leaving the dirty side of dish area and proceeding to the clean side of the dish area/machine.
Observations on 09/19/22 at 10:01 A.M. and 10:37 A.M., showed dietary staff washed dirty dishes in the mechanical dishwashing station. Further observation showed the staff then put away dishes from the clean side of the station without performing hand hygiene.
Observation on 9/20/22 at 11: 34 A.M., showed [NAME] Z used his/her gloved hands to place chicken breasts into a metal pan. The cook removed his/her gloves but did not perform hand hygiene before he/she touched other food related items, which included bottles of spices and the freezer doors.
Observation on 9/20/22 at 12:18 P.M., showed [NAME] AA used his/her gloved hand to pull down his/her facemask by the front of the facemask. He/she did not change gloves and perform hand hygiene before he/she touched serving utensils and resident plates.
Observation on 9/20/22 at 12:21 P.M., showed the DM entered the kitchen with his facemask below his chin. The DM used his bare hand to the front of the facemask to place it over his nose and mouth. The DM did not perform hand hygiene before he touched other food related items, which included the freezer doors and packages of food.
Observation on 9/20/22 at 12:54 P.M., showed DA Y prepared resident drinks during the lunch service. The DA spilled a drink and used a dry, visibly dirty rag from the stove work area to clean up the spill. Further observation showed the DA did not perform hand hygiene before he/she touched the ice scoop and the lip of resident cups.
During an interview on 09/21/22 at 11:59 A.M., the DM said he is responsible to ensure the kitchen is operated according to regulations. He said staff are expected to wash their hands when they enter the kitchen, when they move from dirty to clean activities, and when their hands are contaminated or visibly dirty. The DM said staff have received verbal training on handwashing, and staff have also been instructed to wash their hands after they touch their face or facemask and before they put on or after removing gloves.
During an interview on 09/21/22 at 1:22 P.M., the administrator said the DM is responsible to ensure the kitchen is operated according to regulations. He said the facility has a policy on handwashing in the kitchen, and staff had been trained on the policy. The administrator said it is expected staff would wash their hands when they enter the kitchen, after each task, when moving from dirty to clean activities, after they touch their face or facemask, and before putting on or after removing gloves.
3. Review of the facility's Refrigeration and Freezer Storage policy, dated 11/2017, showed:
-Foods will be stored in their original container or a NSF approved container or wrapped tightly in moisture-proof film, foil, etc. Clearly labeled with the contents and the use by date;
-Once food is cooked, such perishable items must be labeled with the use by date before properly storing in the refrigerator;
-Items (such as soups/casseroles) that may be prepared using previously cooked and stored food must be labeled with the use by date of the previously cooked item;
-Leftovers will be place in an approved container, labeled, dated, and stored in refrigerator or freezer at correct temperature;
-A designated partner will check leftovers on a daily basis and plan for their use.
Review of the facility's Dry Storage policy, dated 11/2017, showed:
-All non-potentially hazardous foods shall be stored in a clean and dry location, not exposed to splash, dust, or other contamination;
-Foods will be stored in their original packages, if possible. If opened, packages should be closed securely to protect the product;
-Products that are not easily identified such as flour, sugar, salt, etc. should be clearly labeled with the common name of the food when removed from original packages.
Review of a sign posted on the reach-in freezer labeled #3, showed Date all items after opening Leftovers and other refrigerated items date 3 days out, do not use after that date. Dry goods, seasoning & spices, gallon size condiments & dressings, and frozen items put a opened on date. Most items that fall in there are good for a year. Even snacks that are not prepackaged including sandwiches needed dated for 3 days out.
Observation on 09/19/22 at 10:04 A.M., showed the walk-in refrigerator contained:
-an opened and undated four quart container of tuna salad;
-an opened and undated six pound container of yellow mustard;
-an opened and undated 48 ounce (oz) container of grape jelly;
-an opened and undated one gallon container of barbeque sauce;
-an opened and undated one gallon container of Caesar dressing;
-an opened and undated one pound container of chicken base;
-an opened and undated 135 oz container of picante sauce;
-an opened and undated 32 oz bottle of lemon juice;
-an opened and undated 32 oz container of minced garlic;
-an opened and undated four pound container of pimento cheese spread;
-an opened and undated one gallon container of mayonnaise;
-an opened and undated one gallon container of sweet pickle relish;
-an opened and undated 32 oz bottle of Caesar dressing;
-an opened and undated five pound bag of shredded mozzarella;
-an opened and undated five pound bag of shredded cheddar cheese;
-an opened and undated five pound bag of grated parmesan cheese;
-an opened and undated 16 oz bag of whipped topping;
-an opened and undated 24 oz package of mild cheddar cheese slices;
-an opened and undated 24 oz. package of provolone cheese slices;
-an opened and undated 32 oz. package of oven roasted turkey slices;
-an opened and undated bag of cooked diced chicken;
-an opened and undated bag of bacon bits;
-an opened and undated bag of hard boiled eggs;
-a 7.5 quart container labeled as cranberry sauce 8/5 use by 8/8;
-an opened and undated five pound container of sour cream;
-two stacks of white cheese slices wrapped in plastic wrap and undated;
-5 pitchers of liquids unlabeled and undated;
-a small metal pan of an unidentified ground food undated and unlabeled;
-a small metal pan of an unidentifiable puree-like substance unlabeled and undated;
-a metal pan of cooked sausage links undated;
-two small blocks of butter opened, wrapped in plastic wrap and undated.
Observation on 09/19/22 at 10:27 A.M., showed the toaster cart contained undated plastic storage containers of cornflakes, frosted cornflakes, raisin bran, cheerios and crisp rice cereal.
Observation on 09/19/22 at 10:42 A.M., showed the dry goods pantry contained:
-four staff personal bags and a cup with straw on the food storage shelf next to containers of peanut butter and spices;
-an opened and undated 35 ounce (oz) bag of crisp rice cereal;
-an opened and undated bag of raisin bran cereal;
-an opened and undated bag of cornflakes;
-an opened and undated one gallon bottle of burgundy cooking wine;
-an opened and undated one gallon bottle of burgundy apple cider vinegar;
-an opened and undated one gallon bottle of corn syrup;
-an opened and undated 96 oz bottle of extra light amber honey;
-an opened and undated one gallon bottle of teriyaki marinade and sauce. Further observation showed the instruction REFRIGERATE AFTER OPENING printed on product label;
-an opened and undated one gallon bottle of soy sauce. Further observation showed the instruction REFRIGERATE AFTER OPENING printed on product label;
-an opened and undated 36 oz bottle of pancake syrup;
-an opened and undated 23 pound container of pre-made fudge icing.
Observation on 09/19/22 at 10:59 A.M., showed the reach-in freezer in the dry goods pantry labeled #2 contained a large opened and undated bag of raspberries.
During an interview on 9/21/22 at 11:59 A.M., the DM said he is responsible to ensure the kitchen is operated according to regulations. He said open food should be labeled, dated, and initialed by staff before it is put away. The DM said staff had been trained on food storage, and he monitors the refrigerators, freezer, and pantry frequently. He said the staff have lockers in the pantry and break room to store their personal items, and it is expected that staff would store their personal items in the appropriate locations and not by food.
During an interview on 9/21/11 at 1:22 P.M., the administrator said the DM is responsible to ensure the kitchen is operated according to regulations and he should monitor food storage daily. He said the facility has policies on food storage and the storage of staff personal items, and staff have been trained on the policies. The administrator said opened food should be labeled, dated, and protected when it is put away; and staff are expected to store personal items in the break room not by food.
4. Review of the facility's Cleaning Equipment policy, dated 11/2017, showed:
- Equipment must be cleaned and/or sanitized after every use and according to manufacturers' directions;
- Work assignments for routine cleaning should be posted and checked daily for completion;
- The physical facilities shall be cleaned as often as necessary to keep them clean.
Observation on 9/20/22 at 2:06 P.M., showed:
- The bottom shelf of the microwave service counter contained a dried white substance. Further observation showed pots and pans stored inverted directly on the white substance;
- The air intake on the ice machine visibly dirty with dust buildup. Further observation showed the air intake located directly over the ice storage bin;
- The air vent over the door in the dishwashing area visibly dirty with dust buildup. Further observation showed clean dishes store directly underneath the vent.
Observation on 9/21/22 at 10:05 A.M., showed:
- The bottom shelf of the microwave service counter contained a dried white substance. Further observation showed pots and pans stored inverted directly on the white substance;
- The air intake on the ice machine visibly dirty with dust buildup. Further observation showed the air intake located directly over the ice storage bin;
-The air vent over the door in the dishwashing area visibly dirty with dust buildup. Further observation showed clean dishes store directly underneath the vent.
During an interview on 9/21/22 at 11:59 A.M., the DM said he is responsible to ensure the kitchen is operated according to regulations. He said the kitchen did not currently have an established cleaning schedule, because he had not had time to put one together. The DM said the dietary staff clean their areas after each service and he checks the kitchen every day for other areas that need to be cleaned.
During an interview on 9/21/22 at 1:22 P.M., the administrator said the DM is responsible to ensure the kitchen is operated according to regulations. He said the facility has a policy on cleaning the kitchen, and staff had been trained on the policy. The administrator said the DM checks the cleanliness of the kitchen every day, and it is expected the kitchen would be dust and dirt free.
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 interview and record review, the facility staff failed to develop and implement policies and procedures for the inspect...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). Additionally, the facility staff failed to use hand hygiene and provide perineal care and catheter (a tube inserted into the bladder) care in a manner to reduce the risk of infection for two residents (Resident #23 and Resident #35). Facility staff failed to ensure all employees were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per policy for four out of ten sampled employees. The facility census was 68.
1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed:
-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit;
-Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:
-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;
-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;
-Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
Review of the facility's inspection, testing and maintenance records showed the records contained a Water Management Program to Reduce Legionella Risk in Facility Water System policy, undated, which directed staff on how to develop a water management program. Review showed the policy directed staff to:
-Utilize tools provided by the CDC and ASHRAE industry standard as guidance in development, implementation, and ongoing evaluation of program to limit Legionella and other waterborne germs from growing and spreading;
-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathoges could grow and spread in the facility water system;
-Identify areas where Legionella could grow and spread by completing an analysis of the current building water system;
-Complete a written description and process flow diagram. Identify waster sources, flow, temperature, stagnation, disinfection, conditions for bacteria spread, special considerations, and external hazards;
-Put control measures into place and how to monitor them utilizing indicators identified on the process flow diagram;
-Establish ways to intervene when control limits are not met;
-Make sure the program is running as designed and is efective.
Further review showed the records did not contain documentation of a water management team, facility water flow description, a risk assessment to identify potential areas for the growth of waterborne pathogens including legionella, control limits, and what actions the facility would take when the control limits are not met.
During an interview on 09/22/22 at 2:05 P.M., the Maintenance Director said he/she did not know anything about a water management program and had only been told the water needed to be tested twice a year by an outside company.
During an interview on 09/22/22 at 10:43 A.M., the administrator said he/she did not have any other information for the water management program beyond the policy. The administrator said he/she just became the administrator that week and did not know why the facility did not have a complete water management program.
2. Review of the facility's Hand Hygiene Policy, dated May 2021, showed:
-There are two methods for hand hygiene: Alcohol-based hand sanitizer and washing the hands with soap and water;
-The Centers for Disease Control (CDC) recommends the following during routine patient care:
-Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal;
-Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to
spores.
Review of the facility's Incontinence Care policy, dated 2006, showed the purpose is to prevent infection, skin breakdown, identify skin problems as soon as possible so treatments can be started, and to keep skin clean, dry, and free of odor and irritation and directs staff to:
-Put on gloves;
-Wash all soiled skin areas, washing from front to back, rinse and dry very well;
-Change linens as necessary;
-Remove gloves;
-Replace incontinence pad or apply disposable diaper as necessary.
Review of Resident #23's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/22/22, showed facility staff assessed the resident as:
-Required physical assistance of two staff for dressing, toileting and transfers;
-Incontinent of bowel and bladder.
Observation on 9/20/22 at 8:18 A.M., showed Certified Nurse Aide (CNA) C entered the room and applied gloves, without performing hand hygiene. The CNA transferred the resident to bed, and performed perineal care. He/She removed his/her gloves, and applied new ones, without performing hand hygiene between glove changes.
During an interview on 9/20/22 at 8:26 A.M., CNA C said he/she should perform hand hygiene before and after care, between dirty and clean task, and when removing his/her gloves, before applying new ones. He/she said they were nervous.
During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said staff are expected to wash their hands before and after providing care, when gloves or hands are visibly soiled, and when they change their gloves.
During an interview on 9/23/22 at 12:17 P.M., the Director of Nursing (DON) said he/she expects staff to refer to the perineal care policy when providing perineal care. He/she said staff should perform hand hygiene before care, anytime gloves are changed and when finished with care.
3. Review of the facility's Urinary Catheter Care Policy, undated, showed:
Nursing Assistants must complete catheter and perineal care with a.m. and p.m. cares, and after each of the resident's bowel movements.
-Always wash your hands before and after handling the catheter, tube or bag, and wear gloves, following standard precautions for infection control;
-Clean the area where the catheter is inserted by wiping away from the insertion site, to prevent germs from being moved from the anus to the urethra;
-Hold the end of the catheter tube to keep it from being pulled while cleaning;
-Do not use powder around the catheter entry site;
-Check for any irritation, redness, tenderness, swelling, drainage or leaking around the catheter entry site.
Review of Resident #35's admission MDS, dated [DATE], showed facility staff assessed the resident as:
-Required physical assistance of two staff for toileting and transfers and limited assistance of one staff for dressing;
-Had an indwelling urinary catheter;
-Occasionally incontinent of bowel;
-Diagnoses of cancer, high blood pressure, renal insufficiency (kidney problems) diabetes, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), malnutrition, and vision problems.
Observation on 9/22/22 at 8:02 A.M., showed CNA R and CNA M entered the resident's room to provide care. CNA R wiped the resident's groin, and with the same wipe, wiped around the catheter insertion site. CNA R then used a new wipe and repeated the process. Observation showed CNA R did not change his/her gloves or sanitize his/her hands before moving from a dirty to clean area.
During an interview on 9/22/22 at 8:18 A.M., CNA R said the area around the catheter insertion site was a cleaner area than the groin. He/She should have removed his/her gloves, washed his/her hands, and reapplied new gloves before he/she cleaned the resident's catheter insertion site.
During an interview on 9/22/22 at 2:32 P.M., CNA M said staff should wash their hands prior to providing care. He/She said wipes should only be used for one swipe, and then a new one should be used.
During an interview on 9/23/22 at 12:17 P.M., the DON said he/she expects staff to refer to the catheter care policy when providing catheter care. He/she said staff should perform hand hygiene before care, anytime gloves are changed and at the end of care. He/she said staff are directed to wash their hands before they touch a catheter, and to clean the catheter by moving from the insertion site outward.
4. Review of the facility's TB Exposure Control Plan Policy, dated 2019, showed:
-Healthcare workers will have a pre-placement and annual TB skin test to assess for possible conversion;
-All staff will have an initial two-step Tuberculin Skin Test (TST) upon hire, and a single-step annual TST.
Review of the facility's Infection Control Manual Volume 1, dated February 2022, showed:
-Baseline testing is administered, and results determined when employment begins;
-The first step TST is to be administered and read prior to assignment of patient care duties;
-The first TST results should be read and documented by a licensed nurse 48-72 hours after the TST is administered, if the test is not read within 72 hours then it should be repeated;
-The second TST should be administered one week after the first TST;
-The second TST should be read and documented after 48-72 hours.
Review of NA E's employee file showed:
-Hire date of 7/27/20;
-First TST administered on 7/27/20.
-Review of the employee file showed staff did not document the results of the first TST and did not document a second TST was administered.
Review of CNA H's employee file showed:
-Hire date of 2/5/22;
-First TST administered on 2/9/22 and read on 2/11/22;
-Review of the employee filed showed staff did not document a second TST was administered.
Review of Housekeeping/Laundry Aide I's employee file showed:
-Hire date of 4/14/22;
-First TST administered on 4/7/22 and read on 4/9/22;
-Review of the employee file showed staff did not document a second TST was administered.
Review of Dietary Aide J's employee file showed:
-Hire date of 7/7/22;
-First TST administered on 6/29/22 and read on 7/1/22.
-Review of the employee file showed staff did not document a second TST was administered.
During an interview on 9/21/22 at 12:02 P.M., the Business Office Manager (BOM) said the Staffing Coordinator keeps the records regarding TB results. He/She said the nurse on duty performs the TB tests.
During an interview on 9/22/22 at 2:15 P.M., the Staffing Coordinator said the initial TST needs to be initiated and read before the employee's first shift. He/She said the second TST needs to be completed within three weeks after the initial TST. He/She did not know why the TB tests were not completed.
During an interview on 9/23/22 at 12:17 P.M., the DON said the Staffing Coordinator keeps the TB test records and follows up on tests. He/She said for new employees the initial TST should be done and read before they start their first working day. He/ She said the second TST should be done about a week after the first one but should not be done after three weeks. He/She didn't know TB tests had not been completed per facility policy.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
Based on interview and record review, facility staff failed to annually and as necessary, conduct, document, review and update their Facility-wide Assessment, an assessment completed by facility staff...
Read full inspector narrative →
Based on interview and record review, facility staff failed to annually and as necessary, conduct, document, review and update their Facility-wide Assessment, an assessment completed by facility staff to determine what resources are necessary to care for its residents competently during day-to-day operations and emergencies. The facility census was 68.
1. Review of the facility's Facility Assessment Tool, dated 8/18/17, showed nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The tool is organized into three parts:
-Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care;
-Services and Care offered based on resident needs (includes types of care your resident population requires; the focus is not to include individual level care plans in the facility assessment);
-Facility resources needed to provide competent care for residents, including staff members, staffing plan, staff members training/education and competencies, education and training, physical environment and building needs, and other resources and systems, a facility-based and community-based risk assessment, and other information you may choose.
Guidelines for conducting the assessment include:
-The facility must review and update this assessment annually or whenever there are facility plans for any change that would require a modification of any part of this assessment.
Further review of the Facility Assessment Tool showed:
-The Resident Profile section was incomplete;
-The Services and Care section was incomplete;
-The Facility Resources section was incomplete.
During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said they do not know what a facility assessment is or whom is responsible to complete it.
During an interview on 9/22/22 at 1:20 P.M., the Director of Nursing (DON) said he/she does not complete the facility assessment. He/She said the Administrator is responsible for ensuring the assessment is completed and updated.
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: 2 life-threatening violation(s), 3 harm violation(s), $135,209 in fines. Review inspection reports carefully.
- • 33 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $135,209 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (6/100). Below average facility with significant concerns.
Bottom line: Trust Score of 6/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Osage Beach Rehabilitation And Health's CMS Rating?
CMS assigns OSAGE BEACH REHABILITATION AND HEALTH CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Missouri, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Osage Beach Rehabilitation And Health Staffed?
CMS rates OSAGE BEACH REHABILITATION AND HEALTH CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 48%, compared to the Missouri average of 46%.
What Have Inspectors Found at Osage Beach Rehabilitation And Health?
State health inspectors documented 33 deficiencies at OSAGE BEACH REHABILITATION AND HEALTH CARE CENTER during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 25 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Osage Beach Rehabilitation And Health?
OSAGE BEACH REHABILITATION AND HEALTH CARE 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 NATIONAL HEALTHCARE CORPORATION, a chain that manages multiple nursing homes. With 94 certified beds and approximately 74 residents (about 79% occupancy), it is a smaller facility located in OSAGE BEACH, Missouri.
How Does Osage Beach Rehabilitation And Health Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, OSAGE BEACH REHABILITATION AND HEALTH CARE CENTER's overall rating (3 stars) is above the state average of 2.5, staff turnover (48%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Osage Beach Rehabilitation And Health?
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 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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Osage Beach Rehabilitation And Health Safe?
Based on CMS inspection data, OSAGE BEACH REHABILITATION AND HEALTH CARE CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 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 Osage Beach Rehabilitation And Health Stick Around?
OSAGE BEACH REHABILITATION AND HEALTH CARE CENTER has a staff turnover rate of 48%, which is about average for Missouri nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Osage Beach Rehabilitation And Health Ever Fined?
OSAGE BEACH REHABILITATION AND HEALTH CARE CENTER has been fined $135,209 across 2 penalty actions. This is 3.9x the Missouri average of $34,431. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Osage Beach Rehabilitation And Health on Any Federal Watch List?
OSAGE BEACH REHABILITATION AND HEALTH CARE 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.