ESTATES OF PERRYVILLE, LLC, THE
For profit - Limited Liability company
156 Beds
Independent
Data: November 2025
7 Immediate Jeopardy citations
Trust Grade
0/100
#378 of 479 in MO
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Families considering The Estates of Perryville, LLC in Perryville, Missouri should be aware that it has a Trust Grade of F, indicating significant concerns about the facility's care. Ranked #378 out of 479 in Missouri, it falls in the bottom half of nursing homes statewide, and is the second out of two options in Perry County. While the facility is showing signs of improvement, decreasing from 13 issues in 2024 to 10 in 2025, it still has a troubling record with 90 total deficiencies, including critical incidents of physical abuse and self-harm attempts. Staffing is a weak point, with only 1 out of 5 stars, and the RN coverage is concerning, being less than 99% of state facilities. Additionally, the facility has incurred $66,532 in fines, which is higher than 78% of Missouri nursing homes, further emphasizing the need for caution.
- Trust Score
- F
- In Missouri
- #378/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $66,532 in fines. Higher than 66% of Missouri facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 3 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 90 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 22%
Review needed
13 → 10 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 53%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Federal Fines: $66,532
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 90 deficiencies on record
7 life-threatening 2 actual harm
Sept 2025
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on record review and interview the facility failed to provide adequate supervision for one of three sampled residents. Resident #1 was assessed as needing 24-hour supervision for safety and had ...
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Based on record review and interview the facility failed to provide adequate supervision for one of three sampled residents. Resident #1 was assessed as needing 24-hour supervision for safety and had a history of making suicidal threats/ideations and aggression towards others and staff. The resident exited the facility's secured behavioral unit without staff knowledge and was gone for approximately 12 hours. Facility staff failed to implement the facility policy for rounding and making observations of residents. While away from the facility, the resident used a broken piece of glass and attempted suicide by inserting it into her skull. The facility census was 100.The administration was notified on 09/11/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred 09/06/25. Upon notification of the elopement on 09/06/25, the facility administration immediately started an investigation and notified the Department of Health and Senior Services of the elopement. The facility installed new window modifications to prevent residents from removing the glass and in-serviced all staff on the facility's policy and procedures for making rounds. The IJ was corrected on 09/06/25. Review of the facility's Rounding Policy, dated 02/24/24, showed:- All residents have the right to be cared for in a safe environment. Rounding will be ensured all resident needs are being addressed and proper supervision is occurring;- Rounds are completed every two hours unless directed by the charge nurse;- Rounds must be made at the beginning and ending of each shift ensuring physically walking into each room and physically seeing each resident;- To be proactive in our care, staff need to be rounding each hour, so the residents use the call lights less, you have less interruptions during your day and the residents are much happier. 1. Review of Resident #1's Level II Preadmission Screening and Resident Review (PASRR) (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 03/02/23, showed:- Requires 24-hour supervision for safety, fall risk;- History of physical behaviors;- Monitoring of behavioral symptoms;- Provision of behavioral support;- Assess and plan for the level of supervision required to prevent harm to self and others;- History of suicidal threats and ideations. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 04/24/24 showed:- Diagnoses of schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia, such as hallucinations and delusions, with symptoms of a mood disorder, like bipolar disorder or depression), personality disorder (personality disorder is a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), impulse disorder (a mental health condition where a person cannot resist the urge to perform an act that is harmful to themselves or others), major depressive disorder (a mood disorder characterized by persistent feelings of sadness, hopelessness, or a loss of interest or pleasure in daily activities, lasting for at least two weeks), and anxiety (excessive fear, worry, and related behavioral disturbances that interfere with daily life);- Cognition intact;- Supervision of staff for activities of daily living;- Rejection of care and evaluation 4-6 days a week;- Ambulates independently. Review of the resident's Care Plan dated 01/21/24, showed:- Resident has a history of making suicidal threats and ideations related to depression;- History of refusals to eat, take medications, or be assessed;- History of verbal and physical aggression towards others and staff;- History of delusions. Review of the facility Self-Report form, dated 09/09/25 regarding Resident #1, showed: - On 09/06/25, police arrived at the building at approximately 8:30 A.M. responding to another resident situation. As Licensed Practical Nurse (LPN) A was walking the police to D Hall secured unit, he/she received a call about a person that was found on the outside of a local store. The officer's exact words he/she has been here (at the store) all night. LPN A asked the officer the name of the individual that had been found, and the officer responded with Resident #1's name. LPN A confirmed that he/she was a resident of facility. LPN A immediately checked Resident #1's room. LPN A contacted the Assistant Director of Nursing (ADON) that Resident #1 had exited the facility sometime the previous night. The ADON contacted the Administrator. Resident #1 had eloped from the facility. Staff initiated a head count on D-hall and the entire building which determined Resident #1 was missing and all other residents were accounted for. The ADON confirmed with the responding officer that Resident #1 arrived at a local liquor store via security camera footage at 3:24 A.M. on 09/06/25. The resident slept on the concrete in-front of the building. The store clerk arrived at 7:00 A.M. The store clerk went back outside at 8:00 A.M. to speak with the resident. The store clerk contacted local police who arrived at the liquor store at approximately 8:24 A.M. Resident #1 informed the police that he/she broke out of the facility to go for a walk and had been walking around the area for a while, before arriving at the liquor store. Emergency Medical Services arrived and transported the resident to the local emergency room. The resident had been missing for approximately 12 hours;- Review of the statements received from the night shift staff who worked during the incident, no one can account seeing the resident after the 8:00 P.M. smoke break. Staff wrote they completed rounds at different times, however, none of them opened the room door to lay eyes on Resident #1. Record review of the hospital report dated 09/06/25 showed:-This is a patient with self-inflicted head wound. He/she discovered a broken piece of glass and attempted suicide by inserting it into his/her skull. He/she continues to harbor suicidal thoughts, primarily due to his/her inability to communicate with family in another state. During a telephone interview on 09/11/25 at 11:15 A.M., Resident #1 said:- He/she left the facility because he/she heard one of the staff yelled at another resident and he/she no longer wanted to be there; - He/she did not know if his/her roommate was in the room when he/she left, but knew the staff would not be around because they all stay at the nurses station on their phones on night shift;- He/she used a rag to open the middle window of his/her room, slid it over and placed the window on his/her bed, busted through the screen and left the facility around 7:30 P.M., stating it was dark outside; - He/she did not have any injuries when crawling out of the window, used the rag because he/she is on blood thinners and did not want to bleed;- He/she just started walking through neighborhoods until he/she reached a gas station or something like that and sat down;- This is where he/she found a piece of glass and attempted to cut his/her head;- He/she said the next thing he/she knew the cops were there and he/she was bleeding from his/her head. Observation on 09/11/25 at 9:45 A.M. of Resident #1's room, showed three intact windows with approximately 4-inch metal plates screwed between each window to prevent the window glass from being raised higher than approximately 10 inches and unable to remove from frame. During an interview on 09/11/25 at 10:20 A.M. Certified Nurse Aide (CNA) B said he/she had seen the resident just a couple of hours prior to leaving his/her shift at 7:00 P.M., the resident was not eating that day due to not feeling well with a urinary tract infection. During an interview on 09/11/25 at 10:25 A.M., CNA C said the resident was his/her normal self on the 7 A.M. to 7 P.M., shift which was easily agitated by others but had not expressed suicidal threats or behaviors. He/she last saw the resident that day at 7:30 P.M., when he/she was leaving his/her shift. During an interview on 09/11/25 at 10:30 A.M., the Social Service Director said he/she had been on the secure unit most of the day noting Resident #1 was in a good mood, sitting in the dining room making the staff a list of all the local restaurants. During an interview on 09/11/25 at 10:35 A.M., the Maintenance Director said the day after the incident he/she installed the metal pieces with screws to each window to prevent the windows from rising enough for someone to crawl out of and or remove the glass from the frame. During an interview on 09/11/25 at 1:15 P.M., the Administrator said she would have expected the staff to perform hourly checks on each resident on the secure units per facility policy.
Sept 2025
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
Jul 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when another resident (Resident #2) open handed slapped the resident, in the face three times. Resident #2 said Resident #1 had behaviors that bothered him/her and hit Resident #1 repeatedly. Resident #1 sustained contusions, redness, and swelling to the right side of his/her face and was sent to the Emergency Department (ED) by ambulance. The facility census was 103.Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 04/08/24 showed:Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident must not be subject to abuse by anyone including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies, family, legal guardians, friends or other individuals:Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Review of Resident #1's medical record showed:The resident was own responsible party;Diagnoses of major depressive disorder (a mental disease characterized by persistent sadness), post traumatic stress disorder (PTSD - a mental health condition that can develop after experiencing or witnessing a traumatic event), Alzheimer's disease (a progressive disease causing loss of cognitive function), traumatic brain injury (TBI - a brain injury caused by physical force or a blow to the head that can affect a person's cognitive function), and paranoid schizophrenia (a mental disorder characterized by disruptions in thought, perception and behavior. Specifically marked by symptoms of paranoia, delusions and hallucinations). Review of the resident's Physician Order Sheet (POS), dated July 2025, showed:An order for Geodon (an antipsychotic medication - used to treat mental health conditions characterized by psychosis) 40 milligram (mg) two times daily, dated 06/05/24;An order for lorazepam (an antianxiety medication) 1 mg three times daily, dated 06/05/25;An order for risperidone (an antipsychotic medication) 2 mg two times daily, dated 12/18/23;An order for venlafexine (an antidepressant medication) 75 mg two times daily, dated 06/05/25.Review of the resident's Care Plan, dated 07/09/25, showed:Requires a supervised environment and supervision with all activities of daily living (ADL) care;Will become physically and verbally aggressive when not getting what he/she asks for and will scream when staff attempt to de-escalate;Psychiatry to follow up and prescribe/manage medications;Smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior;Has intellectual disabilities;Will ask others for money or cigarettes, including staff and other residents;The care plan did not address interventions to manage the resident's escalating behaviors. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/12/25, showed:Some cognitive inabilities; Behaviors of agitation and cursing when upset;Required supervision with all ADLs. Review of the resident's ED medical record, dated 07/06/25, showed:Was treated for assault;Had contusions to the face and right side of the head;Received a new order for Tylenol for pain as needed. Review of Resident #2's medical record showed:The resident had a guardian;Diagnoses of major depressive disorder, schizoaffective disorder bipolar type (a mental disorder characterized by both schizophrenia and a mood disorder - meaning a person may experience psychotic symptoms like hallucinations or delusions along with episodes or mania or depression), impulse disorder (a mental health condition that makes it difficult to control or resist urges which can cause harmful or socially unacceptable behaviors), and anxiety. Review of the resident's POS, dated July 2025, showed:An order for risperidone 4 mg daily at bedtime, dated 04/04/25;An order for Zyprexa (an antipsychotic medication) 10 mg twice daily, dated 04/04/25. Review of the resident's Care Plan, dated 07/04/25, showed:Has a history of racing thoughts, mood instability, agitation, impulse anger issues, paranoia and assaultive behaviors;Has a history of destroying things when getting upset;Has a history of striking other residents;Incarcerated a number of times due to aggressive behaviors;Intervention of staff to attempt to de-escalate the situation and give one-on-one visits and education on coping skills. Review of the resident's annual MDS, dated [DATE], showed:Has a history of disorganized thinking and illogical flow of ideas; Poor judgement and decision making;Delusional and aggressive when upset;Would destroy things when upset. Review of the facility's investigation for the incident on 07/06/25 showed:Resident #1 ran up to Licensed Practical Nurse (LPN) A and said he/she had been struck in the face multiple times by Resident #2. Resident #2 ran up and told LPN A Resident #1 had been asking for money and he/she had gotten tired of it and hit Resident #1;The incident was unwitnessed by any staff;Resident #1 had a red swollen face and was sent to the ED for an assessment. During an interview on 07/09/25 at 10:30 A.M., the Administrator said the incident between Resident #1 and Resident #2 happened on a weekend and the Director of Nursing (DON) made the report. She was unsure of the details or why there was no staff in the hallway to witness the incident. She would expect staff to have been in the hallway to respond. She had no further information on the incident. She did not know what needed to be done to protect Resident #1.During an interview on 07/09/25 at 11:00 A.M., Resident #1 said he/she was struck in the face by Resident #2, it hurt and was scary. It happened in the hallway at the end of the hall right outside Resident #2's room. After he/she told staff, they sent him/her to the ED. His/Her head really hurt all the time. Staff said to just stop bothering the other residents. The facility had not given him/her any new programs or new counseling.During an interview on 07/09/2025 at 11:30 A.M., Resident #2 said Resident #1 kept asking for money and so he/she hit Resident #1. Resident #2 said he/she would have asked for help but there was no staff around in the hallway. Resident #2 said the incident happened right outside his/her room in the hallway. Resident #2 refused to discuss the incident any further. During an interview on 07/09/25 at 1:30 P.M., the Hallway B Social Services Designee (SSD) said the B hallway was full of aggressive residents. He/She tried to monitor the residents but wasn't sure what was going on when he/she was not there. He/She talked with Resident #1 and educated on using his/her coping skills. The SSD said he/she hoped that would benefit Resident #1 and was not aware of any new programs or counseling for the resident. He/She was not aware there had been an incident with Resident #1 getting hurt and had no information regarding the incident. During an interview on 07/09/2025 at 1:40 P.M., the DON said the resident had behaviors, but the facility couldn't give into his/her requests, or he/she would only continue to do it all day. The facility did not incorporate any new programs, and they did not monitor the resident every 15 minute.During an interview on 07/16/2025 at 11:00 A.M., LPN B said he/she was in the office when Resident #1 ran in and said Resident #2 had struck him/her three times in the face. Resident #1's face appeared to be swelling and discolored. The physician was notified, and the resident was sent to the ED. LPN B did not witness the incident. LPN B said there was staff on the hallway, and they must have been attending to other residents.
Jun 2025
5 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when a staff member punched the resident in the face. Resident #1 was observ...
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Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when a staff member punched the resident in the face. Resident #1 was observed with escalating behaviors and pushed a staff member. Certified Nurse Aide (CNA) A approached the fighting resident and staff member and proceeded to punch Resident #1 with a closed fist, in the right eyesocket. This resulted in an injured eyelid and broken nose for Resident #1. The census was 101.
The administration was notified on 06/10/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred 06/05/25. On 06/05/25, upon notification, the facility administration immediately started an investigation, notified the police department and the Department of Health and Senior Services of the physical abuse. The facility terminated employment of CNA A and in-serviced all staff on the facility's policy and procedures for abuse and neglect. The IJ was corrected on 06/05/25,
Review of the facility's policy on Abuse, Neglect and Exploitation Policy, dated 04/08/24 showed:
- Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The resident must not be subject to abuse by anyone including but not limited to: facility staff; other residents; consultants or volunteers; staff of other agencies; family; legal guardians; friends or other individuals.
- Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain, or mental anguish.
Review of Resident #1's face sheet showed:
- The resident is his/her own responsible party;
- The diagnoses included major depression disorder (a mental disease characterized by persistent sadness), Post Traumatic Stress Disorder (PTSD) (a life changing mental health disorder that can occur after a traumatic event causing significant impair to daily life), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), Alzheimer's (a progressive disease causing loss of cognitive function), and Paranoid Schizophrenia (a mental disorder characterized by disruptions in thought, perception, and behavior. Specifically marked by symptoms of paranoia, delusions and hallucinations.)
Review of Resident #1's Active Order Summary (Physician's Orders) current as of 06/10/25 showed:
- An order for behavior monitoring every shift started 05/10/24; (Documentation of behavior monitoring was not provided.)
- An order for geodon (antipsychotic) 40 milligrams (mg) by mouth twice a day with meals for paranoid schizophrenia started on 06/06/25;
- An order for lorazepam (anti-anxiety) injection solution 2 mg/milliliter (ml) every 8 hours as needed for agitation for 14 days started 06/05/25;
- An order for lorazepam oral tablet 1 mg by mouth three times a day started 06/06/25;
- An order for risperidone (antipsychotic) oral tablet 2 mg two times a day for schizophrenia started 12/18/23.
Review of Resident #1's care plan dated 06/12/24 showed:
- The resident requires a supervised environment and supervision with all activities of daily living (ADL) care;
- The resident will become physically and verbally aggressive when not getting what he/she has asked for and will scream when staff attempt to de-escalate;
- Psychiatry to follow up and prescribe/manage medications;
-The resident smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior;
- The resident has intellectual disabilities;
- There were no documented interventions in place for helping to manage the resident's escalating behaviors.
Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 03/12/25, showed:
- The resident has some cognitive inabilities;
- The resident requires supervision with all aspects of daily ADLs.
Review of the facility's investigation dated 06/05/25 showed:
- On 06/05/25 at approximately 6:00 A.M., Resident #1 approached Registered Nurse (RN) B and requested a cigarette and a soda;
- RN B told the resident he/she would have to wait until the scheduled smoke time at 8:00 A.M.;
- The resident was becoming agitated and the RN exited the office to avoid being in an enclosed office with the resident;
- Certified Nurse Aides (CNAs) A, C, and D were in the hallway by the office and told the resident again he/she would have to wait until 8:00 A.M.;
- The resident grabbed a hold of CNA C and appeared to be pushing the CNA down the hall;
- CNA A approached the resident and CNA C, and struck the resident in the right eye causing bleeding;
- An ambulance was called, and the resident was taken to the hospital;
- The hospital noted a nasal fracture and blood in the resident's lower eye lid.
During an interview on 06/10/25 at 11:50 A.M., RN B said he/she has received no formal training in mental health prior to working at the facility. He/she said the resident is triggered by wanting to smoke and becomes agitated when told no. The staff is aware of this trigger and behavior due to the resident doing it every day. He/she said nothing else was offered to the resident, due to he/she was taking report at that time. When the resident became agitated, he/she walked out of the office into the hallway. The resident grabbed CNA C and CNA A walked up and punched the resident in the right eye with a closed fist. The resident walked off and then said, is my eye bleeding. RN B said it is not safe to work at the facility. There is no recourse when a resident attacks or becomes agitated.
During an interview on 06/10/25 at 12:10 P.M., CNA D said he/she was in the hallway, and heard RN B tell the resident that he/she would have to wait until 8:00 A.M. to smoke. The resident was very agitated, and they could not calm him/her down. CNA D said he/she was not looking at the resident when CNA A punched him/her. The resident walked off and asked if he/she was bleeding. He/she said they have rules and regulations, but no training in mental health prior to working.
During an interview on 06/10/25 at 12:15 P.M., CNA C said the resident was agitated because RN B told him/her to wait to smoke until smoke break. The resident grabbed him/her and had both hands on his/her shirt collar. CNA A stepped in, drew back his/her closed fist. CNA C closed his/her eyes and felt CNA A punch the resident causing the resident to spin around and become disoriented. The resident released CNA C and walked away into the shower. The resident then returned saying is my eye bleeding. CNA C said there was no warning from CNA A. He/She just stepped in, punched Resident #1 and stepped back. They provide rules to read, but no training prior to starting work.
During an interview on 06/10/2025 at 12:30 P.M., CNA A said on 06/05/25, at approximately 5:30 A.M., the resident walked out of his/her room with a cigarette. The residents are not supposed to have cigarettes in their room. CNA A told the resident it was not time to smoke. The resident became agitated and acted like he/she was going to throw a table at CNA A. CNA A said he/she told the resident that it was not time to smoke and that he/she (the resident) was aware of the rules. CNA A said the resident has been aggressive with staff before. CNA A told the resident to calm down and the resident walked away, upset. CNA A said the resident came back out and lunged at him/her again and was told again to stop by CNA A. The resident entered the nurse's office and told RN B that he/she wanted a cigarette and a soda. After being told no again, the resident seemed more agitated, and RN B came out of the office. The resident charged at CNA C and it appeared the resident was going to swing at CNA C. CNA A felt the resident was going to hit him/her due to the resident still being angry and he/she swung and hit the resident. CNA A said his/her hand was open. CNA A said it was self-defense. CNA A said he/she only hit the resident once and could have hit more, but did not. Most people would have hit more than once. CNA A said he/she did not hit the resident hard. After the hit, the resident went into the shower room and CNA A believes Resident #1 self-inflicted the injuries. The facility does not offer any training or guidance for this type of problem. CNA A said the staff are in danger with the residents who have these behaviors.
During an interview on 06/10/25 at 1:30 P.M., Resident #1 said he/she had wanted a cigarette and was really upset. The resident said he/she would never hit a girl. The resident said he/she did not have his/her hands on CNA C. Someone did have hands on his/her shoulders and the resident said he/she was only trying to get loose. The resident said he/she did not realize CNA A had punched him/her in the eye, but only saw a flash of light. No one had ever hit him/her before. The resident said he/she had just wanted a cigarette, but after getting punched the staff provided the resident with a cigarette.
During an interview on 06/10/25 at 1:45 P.M., local law enforcement (LE) said the resident did not want to press charges. He/she feels the staff at the facility know the residents have mental problems and they instigate them by denying them coffee or cigarettes. When the resident reacts and becomes aggressive, they want LE to come and take the resident away.
During an interview on 06/10/25 at 11:00 A.M., the Director of Nurses (DON) said the resident has a history of demanding to smoke before the scheduled smoke breaks. If the resident is told no, he/she will react and become aggressive. She said staff reported that on 06/05/25, the resident came out of the room at approximately 5:45 A.M. The resident went to the nurses' office on B hallway. He/she wanted to smoke and have a soda. The day shift charge nurse, RN B told the resident no, he/she would have to wait until the designated smoke break. This upset the resident and caused more agitation. The nurse came out of the office into the hallway to avoid close contact with the resident. Three CNAs, A, C, and D were in the hallway, and they also told the resident he/she would have to wait. This continued to anger the resident. At this time, the resident grabbed onto CNA C by the shirt and was pushing CNA C down the hallway. CNA A then approached the resident and struck the resident in the right eye with a closed fist. She said the nurse did not offer to let a staff member take the resident to smoke. The staff did not attempt to de-escalate the resident with any other options. She said that this is a trigger for the resident and the staff is aware of this. If staff had tried to offer other options, it might have prevented the resident from being so agitated. She said the staff gets training and in-servicing on abuse and neglect. They are trained on de-escalation, but have no formalized mental health training in place. They are supposed to read a training manual prior to taking the floor. They are to sign a sheet that they have read the manual. The facility does not monitor and there is no way to ensure they have read the rules and policies provided in the manual.
During an interview on 6/10/25 at 1:50 A.M., the Medical Director (MD) said CNA A would have had to hit the resident very hard to crack the resident's nose. The MD said there is an element of danger in working with these type of behaviors, but staff should never hit any resident. The staff cannot accommodate this resident every time the resident wants something or they would have to do it for all residents.
MO255323, MO255327
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 F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to have documenation of one resident with serious mental illness and intellectual disability diagnoses (Resident #1's) Level I preadmission sc...
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Based on interview and record review, the facility failed to have documenation of one resident with serious mental illness and intellectual disability diagnoses (Resident #1's) Level I preadmission screening/resident review (PASRR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities (IDD) completed before admission to the nursing facility or the more indepth Level II PASRR screening in the resident's record to ensure they were able to meet the resident's behavioral needs. The census was 74.
The facility did not provide a policy related to PASRR screenings.
Review of Resident #1's medical records showed:
-The resident is his/her own responsible party;
-The resident had diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), Alzheimer's (a progressive disease causing loss of cognitive function) and Paranoid Schizophrenia (a mental disorder characterized by disruptions in thought, perception, and behavior;
-No PASRR level I screen found;
-No PASRR level II screen found.
Review of Resident #1's care plan, dated 06/12/24, showed:
- Level I/ Level II PASRR screening completed. Resident determined to have severe mental illness with diagnoses including PTSD and intellectual disabilities;
- The following interventions were included:
- Address, report, and implement plan to manage refusals/ noncompliance For example, Notify Provider/ Responsible Party of instances of noncompliance, ascertain immediate safety, and/or sending to acute setting for evaluation of mental deterioration;
- Assess and plan for level of supervision required to prevent harm or self/ others;
- Medication set and administration by staff and monitor compliance with prescription;
- Monitor and plan for assaultive behaviors, as well as how to de-escalate and help regulate moods/behaviors;
- Monitor for elopement or medication refusals, symptoms of rapid decline in mood, escalating aggressive or sexual behavior, confusion or bizarre thoughts;
- Monitor therapeutic effects in managing mental health symptoms, including labs as ordered;
- Provide a structured/ stable environment in order to maintain mood stability/ safety;
- Provide for individual personal space and sensory support.
The facility did not provide Resident #1's PASRR.
During an interview on 06/17/25, a Central Office Medical Review Unit (COMRU) nurse stated a Level 2 screening had been completed on the resident in the past, however, the facility would be required by the Department of Mental Health to complete a replacement application since the Level 2 screening was greater than a year old, to ensure it accrately reflects the resident's current behavioral health needs.
MO255323, MO255327
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 F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Residents #1) with a diagnosis of post traumatic stress disorder (...
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Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Residents #1) with a diagnosis of post traumatic stress disorder ((PTSD) - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). The facility's census was 101.
The facility did not provide a policy on trauma-informed care or behavioral health management.
Review of Resident #1's face sheet showed:
- The resident was his/her own responsible party;
- The resident had diagnoses of PTSD, major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), and Alzheimer's (a progressive disease causing loss of cognitive function).
Review of Resident #1's Active Order Summary (Physician's Orders) current as of 06/10/25 showed:
- An order for behavior monitoring every shift started 05/10/24;
- An order for geodon (antipsychotic) 40 milligrams (mg) by mouth twice a day with meals for paranoid schizophrenia started on 06/06/25;
- An order for lorazepam (anti-anxiety) injection solution 2 mg/milliliter (ml) every 8 hours as needed for agitation for 14 days started 06/05/25;
- An order for lorazepam oral tablet 1 mg by mouth three times a day started 06/06/25;
- An order for risperidone (antipsychotic) oral tablet 2 mg two times a day for schizophrenia started 12/18/23.
Review of Resident #1's care plan dated 06/12/24 showed:
- The resident requires a supervised environment and supervision with all activities of daily living care;
- The resident will become physically and verbally aggressive when not getting what is asked for and will scream when staff attempt to de-escalate;
- The resident smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior;
- The resident has intellectual disabilities;
- The resident's PTSD is triggered if he/she does not get his medications on time. The interventions included following the directions given by staff and working on his/her coping skills. No further directions for staff on de-escalation (redirection or alternatives);
- There were no documented interventions in place for helping resident to manage his/her escalating behaviors.
Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 03/12/25, showed:
- The resident has some cognitive inabilities;
- The resident requires supervision with all aspects of daily activities of life (ADL).
During an interview on 06/10/25 at 11:50 A.M., Registered Nurse (RN) B said he/she has received no formal training prior to working at the facility. He/she is agency staff. He/she said the resident is triggered by wanting to smoke and becomes agitated when told no.
During an interview on 06/10/25 at 12:15 P.M., CNA C said the resident is triggered by wanting to smoke and being told no. He/she does it to try to get cigarettes.
During an interview on 06/10/25 at 11:00 A.M., the Director of Nurses (DON) said the resident has a history of demanding to smoke before the scheduled smoke breaks. If the resident is told no, he/she will react and become aggressive. She said the staff are aware of the resident's triggers and should attempt to keep him/her from escalating. The DON said his/her PTSD can be triggered when he/she perceives his/her medications as being given late. She is unaware of what interventions are in place for that on the care plan.
MO255323, MO255327
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 F0741
(Tag F0741)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide staff with appropriate behavioral health training to develop competencies and skill sets in order to to provide services to ensure ...
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Based on interview and record review, the facility failed to provide staff with appropriate behavioral health training to develop competencies and skill sets in order to to provide services to ensure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for one sampled resident (Resident #1) when staff failed to implement de-escalation interventions when Resident #1 began exhibiting increased behaviors. The facility census was 74.
The facility did not provide a policy on behavioral health management.
Review of Resident #1's face sheet showed:
- The resident is his/her own responsible party;
- The resident has diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), Alzheimer's (a progressive disease causing loss of cognitive function).
Review of Resident #1's Active Order Summary (Physician's Orders) current as of 06/10/25 showed:
- An order for behavior monitoring every shift started 05/10/24; No documentation of behavior monitoring completed by the facility was provided.
- An order for geodon (antipsychotic) 40 milligrams (mg) by mouth twice a day with meals for paranoid schizophrenia started on 06/06/25;
- An order for lorazepam (anti-anxiety) injection solution 2 mg/milliliter (ml) every 8 hours as needed for agitation for 14 days started 06/05/25;
- An order for lorazepam oral tablet 1 mg by mouth three times a day started 06/06/25;
- An order for risperidone (antipsychotic) oral tablet 2 mg two times a day for schizophrenia started 12/18/23.
Review of Resident #1's care plan, dated 06/12/24, showed:
- The resident requires a supervised environment and supervision with all ADL care;
- The resident will become physically and verbally aggressive when not getting what is asked for and will scream when staff attempts to de-escalate;
- The resident smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior;
- The resident has intellectual disabilities;
- There are no documented interventions in place for keeping resident from escalating behaviors;
- The staff should attempt to accommodate the requests and needs in an effort to prevent escalation.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/12/25, showed:
- The resident has some cognitive inabilities;
- The resident requires supervision with all aspects of daily activities of life (ADL).
During an interview on 06/10/25 at 11:00 A.M., the Director of Nurses (DON) said the resident has a history of demanding to smoke before the scheduled smoke breaks. If the resident is told no, he/she will react and become aggressive. She said the staff are aware of the resident's triggers and should attempt to keep him/her from escalating. There is no reason the staff staff on de-escalation, but do not have any formal training on mental health disorders. She said staff reported that on 06/50/25, the resident came out of the room at approximately 5:45 A.M. The resident went to the nurses' office on B hallway. He/she wanted to smoke and have a soda. The day shift charge nurse, Registered Nurse (RN) B told the resident no, he/she would have to wait until the designated smoke break. This upset the resident and caused more agitation. The nurse came out of the office into the hallway to avoid close contact with the resident. Three Certified Nurse Aides (CNAs), A, C and D were in the hallway, and they also told the resident he/she would have to wait. This continued to anger the resident. At this time, the resident grabbed onto CNA C by the shirt and was pushing the CNA C down the hallway. CNA A then approached the resident and struck the resident in the right eye. She said the nurse did not offer to let a staff member take the resident to smoke. The staff did not attempt to de-escalate the resident with any other options. She said that this is a trigger for the resident and the staff is aware of this. If staff had tried to offer other options, it might have prevented the resident from being so agitated. She said the staff does get training and in-servicing on abuse and neglect. The four staff members involved are all agency staff. They are supposed to read a training manual prior to working the floor. They are to sign a sheet that they have read the manual. The facility does not monitor and there is no way to ensure they have read the rules and policies provided in the manual.
During an interview on 06/10/25 at 11:50 A.M., RN B said he/she has received no formal training prior to working at the facility. RN B said the resident is triggered by wanting to smoke and becomes agitated when told no. The resident will lash out at staff when angry. He/she said it is impossible to accommodate the resident every time he/she wants to smoke or have a soda. He/she said nothing else was offered, due to he/she was taking report at that time. When the resident became agitated, he/she walked out of the office into the hallway. RN B said it is not safe to work at the facility. There is no recourse when a resident attacks or becomes agitated. There is no need for mental health training as it allows for resident's to be taken down or restrained and this is a no touch facility.
During an interview on 06/10/2025 at 12:30 P.M., CNA A said on 06/05/25, at approximately 5:30 A.M., the resident walked out of his/her room with a cigarette. The residents are not supposed to have cigarettes in their room. CNA A told the resident it was not time to smoke. The resident became agitated and acted like he/she was going to throw a table at CNA A. CNA A said he/she told the resident that it was not time to smoke and that he/she (the resident) was aware of the rules. CNA A said the resident has been aggressive with staff before. CNA A told the resident to calm down and the resident walked away, upset. CNA A said the resident came back out and lunged at him/her again and was told again to stop by CNA A. The resident entered the nurse's office and told RN B that he/she wanted a cigarette and a soda. After being told no again, the resident seemed more agitated, and RN B came out of the office. The resident charged at CNA C and it appeared the resident was going to swing at CNA C. CNA A felt the resident was going to hit him/her due to the resident still being angry and he/she swung and hit the resident. CNA A said his/her hand was open. CNA A said it was self-defense. CNA A said he/she only hit the resident once and could have hit more, but did not. Most people would have hit more than once. CNA A said he/she did not hit the resident hard. After the hit, the resident went into the shower room and CNA A believes Resident #1 self-inflicted the injuries. The facility does not offer any training or guidance for this type of problem. CNA A said the staff are in danger with the residents who have these behaviors.
During an interview on 06/10/25 at 1:45 P.M., local law enforcement (LE) said his/her people see so many problems at this facility which are the results of poor decisions by staff. Staff know the residents have mental problems, but continue to instigate them by denying them coffee or cigarettes. When the resident reacts and becomes aggressive, they want LE to come and take the resident away.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and p...
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Based on observation, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one resident (Resident #1) with severe mental illness and behaviors, when Resident #1 displayed agitated behaviors and staff did not attempt to de-escalate. The census was 74.
The facility did not provide a policy on behavioral health management.
Review of Resident #1's face sheet showed:
- The resident is his/her own responsible party;
- The resident has diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), Alzheimer's (a progressive disease causing loss of cognitive function).
The facility did not provide a PASRR for Resident #1
Review of Resident #1's Active Order Summary (Physician's Orders) current as of 06/10/25 showed:
- An order for behavior monitoring every shift started 05/10/24; No documentation of behavior monitoring completed by the facility was provided.
- An order for geodon (antipsychotic) 40 milligrams (mg) by mouth twice a day with meals for paranoid schizophrenia started on 06/06/25;
- An order for lorazepam (anti-anxiety) injection solution 2 mg/milliliter (ml) every 8 hours as needed for agitation for 14 days started 06/05/25;
- An order for lorazepam oral tablet 1 mg by mouth three times a day started 06/06/25;
- An order for risperidone (antipsychotic) oral tablet 2 mg two times a day for schizophrenia started 12/18/23.
Review of Resident #1's care plan, dated 06/12/24, showed:
- The resident requires a supervised environment and supervision with all ADL care;
- The resident will become physically and verbally aggressive when not getting what is asked for and will scream when staff attempts to de-escalate;
- The resident smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior;
- The resident has intellectual disabilities;
- There are no documented interventions in place for keeping resident from escalating behaviors;
- The staff should attempt to accommodate the requests and needs in an effort to prevent escalation.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/12/25, showed:
- The resident has some cognitive inabilities;
- The resident requires supervision with all aspects of daily activities of life (ADL).
During an interview on 06/10/25 at 11:00 A.M., the Director of Nurses (DON) said the resident has a history of demanding to smoke before the scheduled smoke breaks. If the resident is told no,he/she will react and become aggressive. She said the staff are aware of the resident's triggers and should attempt to keep him/her from escalating. There is no reason the staff staff on de-escalation but do not have any formal training on mental health disorders. She said staff reported that on 06/50/25, the resident came out of the room at approximately 5:45 A.M. The resident went to the nurses' office on B hallway. He/she wanted to smoke and have a soda. The day shift charge nurse, RN B told the resident no, he/she would have to wait until the designated smoke break. This upset the resident and caused more agitation. The nurse came out of the office into the hallway to avoid close contact with the resident. Three CNA ' s, A, C and D were in the hallway, and they also told the resident he/she would have to wait. This continued to anger the resident. At this time, the resident grabbed onto the CNA C by the shirt and was pushing the CNA C down the hallway. The CNA A then approached the resident and struck the resident in the right eye. She said the nurse did not offer to let a staff member take the resident to smoke. The staff did not attempt to de-escalate the resident with any other options. She said that this is a trigger for the resident and the staff is aware of this. If staff had tried to offer other options, it might have prevented the resident from being so agitated. She said the staff does get training and in-servicing on abuse and neglect. The four staff members involved are all agency staff. They are supposed to read a training manual prior to taking the floor. They are to sign a sheet that they have read the manual. The facility does not monitor and there is no way to ensure they have read the rules and policies provided in the manual.
During an interview on 06/10/25 at 11:50 A.M., RN B said he/she has received no formal training prior to working at the facility. RN B said the resident is triggered by wanting to smoke and becomes agitated when told no. The resident will lash out at staff when angry. He/she said it is impossible to accommodate the resident every time he/she wants to smoke or have a soda. He/she said nothing else was offered, due to he/she was taking report at that time. When the resident became agitated, he/she walked out of the office into the hallway. RN B said it is not safe to work at the facility. There is no recourse when a resident attacks or becomes agitated. There is no need for mental health training as it allows for resident's to be taken down or restrained and this is a no touch facility.
During an interview on 06/10/25 at 1:45 P.M., local law enforcement (LE) said the resident did not want to press charges. LE was not aware Resident #1 would be a special victim at first, and is now requesting information on the resident and referring this matter to the Prosecutor. LE said his/her people see so many problems which are the results of poor decisions by staff. Staff know the residents have mental problems, but continue to instigate them by denying them coffee or cigarettes. When the resident reacts and becomes aggressive, they want LE to come and take the resident away.
During an interview on 06/10/25 at 1:50 A.M., the Medical Director (MD) said CNA A would have had to hit the resident very hard to crack the resident ' s nose. MD said there is an element of danger in working with these type of behaviors but staff should never hit any resident. The staff cannot accommodate Resident #1 every time the he/she wants something or they would have to do it for all residents.
MO255323, MO255327
Mar 2025
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse from another resident when staff failed to prevent Resident #2 from hitting Resident ...
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Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse from another resident when staff failed to prevent Resident #2 from hitting Resident #1 which caused a hematoma (a collection of blood outside of the blood vessel) to the left side of the head. The facility also failed to ensure the resident was free from abuse from staff when staff removed Resident #1 from his/her room against their will, and rolled him/her onto a blanket and dragged the resident on the floor through the facility causing the resident to become anxious and require medication to calm down. The census was 120.
On 02/25/25 at 3:30 P.M., the Administrator was notified of the immediate jeopardy (IJ) which began on 02/06/25. The IJ was removed on 02/27/25, as confirmed by surveyor onsite verification.
Review of the facility's policy on Resident to Resident Altercations, updated 01/24/24, showed:
-The staff member on the scene will immediately call a Code Gray on the walkie/talkie and/or overhead intercom;
-Team members will attempt to separate residents and ensure the safety of all residents;
-The team members will remain in the area of the disruption until further assistance arrives.
Review of the facility's Abuse, Neglect and Exploitation Policy, dated 04/08/24, showed:
-Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The resident must not be subject to abuse by anyone including but not limited to: facility staff; other residents; consultants or volunteers; staff of other agencies; family; legal guardians, friends or other individuals.
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish.
1. Review of Resident #1's face sheet showed:
-Had a Public Administrator as a guardian;
-Diagnoses of Schizoaffective Disorder-Bi Polar type (a mental health disorder involving depression, hallucinations and delusions with bouts of manic behavior), and heart failure.
Review of Resident #1's annual Minimum Data Set ((MDS) a federally mandated assessment instrument completed by the facility staff), dated 01/29/25, showed:
- The resident was cognitively intact;
- The resident triggered for delirium (confused thinking, agitation and memory problems), cognitive loss, and falls.
Review of Resident #1's Care Plan, dated 03/05/25, showed:
- The resident required supervision with all activities of daily living (ADLs);
- The resident had a history of aggression and throwing urine on others;
- The resident had impaired cognitive thought processes;
- The resident resided on a secured behavior unit until 02/06/25.
Review of Resident #2's face sheet showed:
- Diagnoses of Autistic Disorder (a lifelong disorder affecting how a person communicates, interacts with others and behaves), Schizophrenia (a mental health disease affecting how a person thinks including delusions, paranoia and hallucinations), and delusional disorder (a serious mental illness causing unshakeable false beliefs).
Review of the resident's quarterly MDS dated , 02/06/25 showed the resident was cognitively intact and no behaviors listed.
Review of Resident #2's care plan, updated 03/05/25, showed:
- The resident becomes agitated if medications aren't on time;
- The resident had delusions and hits staff and other residents without warning;
- The resident had a history of frustration, agitation, impatience and striking others;
- The resident resided on a secured behavior unit;
- The resident was placed on 1:1 on 11/14/24.
Review of the facility's investigation, dated 02/06/25, showed:
- On 02/06/25, Resident #2 asked Certified Medication Technician (CMT) A for medications;
- CMT A informed Resident #2 it was too early for the medications;
- Resident #2 was on one on one with a designated staff member, Certified Nurse Aide (CNA) B, due to a history of aggressive behaviors;
- The resident became agitated and started to walk down the hallway;
- CMT A was afraid of Resident #2 and locked himself/herself in a clean linen closet;
- CNA B and Licensed Practical Nurse (LPN) C, followed Resident #2 halfway down the hall and stopped two rooms away;
- Resident #2 went to the end of the hallway and stared into Resident #1's room for a period of a few minutes;
- CNA B and LPN C watched as Resident #2 raised his/her arms up and ran into the room of Resident #1 and hit Resident #1 in the head;
- Resident #1 sustained a hematoma (damaged blood vessels surrounding the tissue).
During an interview on 02/25/25 at 2:00 P.M., CMT A said Resident #2 becomes very agitated and angry when he/she is told it is not time for his/her medication administration. CMT A said Resident #2 became very threatening toward him/her (on 2/6/25), so he/she removed himself/herself from the situation by hiding in the closet. CMT A said he/she did not feel CNA B and LPN C would be able to handle Resident #2 if he/she escalated in behaviors, and that is why he/she hid. CMT A said he/she peeked out of the closet and saw Resident #2 enter Resident #1's room. CMT A heard Resident #1 yelling for help. LPN C and CNA B stood at least two room doors away and did not attempt to de-escalate Resident #2 or prevent Resident #2 from hitting Resident #1.
During an interview on 02/25/25 at 3:15 P.M., LPN C said CNA B had been assigned to monitor Resident #2 in a one on one capacity due to the resident's history of aggressive behaviors toward other residents. Resident #2 asked CMT A for a medication and CMT A told the resident it was too early. Resident #2 became agitated. When Resident #2 started to walk down the hallway, he/she and CNA B followed. LPN C said they had watched Resident #2 standing at the doorway to Resident #1's room and they stood back down the hall to provide the resident space and not approach him/her. They were two rooms behind Resident #2 observing, when Resident #2 ran into Resident #1's room and hit Resident #1. LPN C said he/she and CNA B then ran toward Resident #1's room and stopped Resident #2 from hitting Resident #1 again. LPN C said when Resident #2 had become agitated the staff should have intervened to protect Resident #1. LPN C did not say why he/she did not intervene and attempt to de-escalate Resident #2 before he/she struck Resident #1.
During an interview on 02/25/25 at 4:20 P.M., CNA B said he/she had been assigned to monitor Resident #2 one on one, due to the resident's history of hitting other residents in the head. Resident #2 was agitated due to not getting the medication he/she requested. Resident #2 started down B Hall while he/she and LPN C followed, but not too closely. He/she said they stood about two rooms away. CNA B said Resident #2 stood at the doorway of Resident #1's room for awhile then raised his/her arms and took off toward Resident #1 striking him in the head. CNA B said he/she and LPN C then ran toward Resident #1's room and heard him/her screaming. They intervened and stopped Resident #2 from striking the resident again. He/she felt CMT A was trying to stay away from Resident #1. CNA B did not say why he/she or LPN C did not attempt to stop Resident #2 from striking Resident #1 the first time.
During an interview on 02/25/25 at 9:45 A.M., the Administrator (ADM) said he would expect all staff to protect the residents. He said staff are afraid of Resident #2 due to his/her size and strength. He expected the staff, CNA B and LPN C, to have stopped Resident #2 from hitting Resident #1. CNA B and LPN C should have called for assistance, but no Code Gray (in policy) that staff did not call for assistance when the resident became agitated knowing he had a history of attacking other residents
2. Review of the facility's investigation, dated 02/08/25, showed:
- Resident #1 was removed from the B Hall after an incident involving Resident #2;
- Resident #1 did not want to leave B Hall and went back to B Hall during the evening hours at approximately 10:00 P.M. to go to his/her old room;
- Staff members LPN D and CNA E approached the resident and attempted to get Resident #1 redirected to his/her new hall;
- Resident #1 sat in the floor and refused to get up;
- Resident #1 continued to refuse to leave the B hall and laid in the floor while staff attempted to pull him/her to a standing position;
- LPN D then placed a blanket on the floor and physically rolled Resident #1 onto the blanket;
- LPN D and CNA E dragged the blanket and Resident #1 on the floor down B hall, through the lobby to his/her new room on A Hall at 11:30 P.M.
Review of Resident #1's Medication Administration Record (MAR), dated February 2025, showed:
- An order for Lorazepam (a drug used to treat anxiety) injection solution 2 milligram (mg) every 6 hours as needed for anxiety;
- Lorazepam injection solution 2 mg given to Resident #1 on 02/07/2025 at 12:30 A.M.
During an interview on 3/6/2025 at 10:20 A.M., CNA E said during the evening, Resident #1 came onto the B hall and said his/her room was there. The other staff members on the hallway told the resident that he/she needed to return to the A hall where the resident had been relocated to earlier that day. The resident sat on the floor and wanted to remain there. The charge nurse, LPN D, came to the B hall and told the resident he/she had to leave. CNA E said he/she requested multiple times to allow the resident to just remain on the floor and calm down and then redirect. LPN D got a blanket to put on the floor, rolled the resident onto the blanket and instructed CNA E to grab a corner and pull. LPN D drug the resident through the hallway to the A hallway. CNA E told LPN D this was not right. CNA E asked LPN D if he/she should write a statement and LPN D said no.
During an interview on 3/6/2025 at 11:30 A.M., LPN D said on 02/06/25 when Resident #1 entered B hall the staff called him/her to come to the hall. Resident #1 was sitting in the hallway by the room that had previously been his/her room and wanted to go in. Staff, unknown to LPN D, were attempting to get the resident to stand up and the resident laid on the floor. LPN D said he/she tried to redirect. The staff said the resident had been attacked earlier and it was not safe to be there. LPN D said he/she attempted to reach the facility's Director of Nurses and on call staff and no one answered. He/she decided the resident needed to be moved to ensure his/her safety. He/she used the fireman blanket transfer (a blanket used to transfer people in emergency situations safely) to move the resident safely. The resident was pushed onto a blanket then rolled into the blanket. LPN D then had CNA E assist in dragging the blanket from Hall B, through the lobby to A hall. The resident was anxious and appeared nervous, but was not yelling or being aggressive at that time. Later in the shift Resident #1 became increasingly anxious and a Lorazepam injection solution 2 mg was administered on 02/07/2025 at approximately 12:30 A.M. LPN D felt it was the only way to ensure the resident was safe.
During an interview on 02/25/25 at 9:45 A.M., the ADM said the two staff should not have treated the resident this way. He would have expected his other staff members to intervene with the physical abuse and did not understand why no staff stopped this from happening.
COMPLAINT #MO249374
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0741
(Tag F0741)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide staff with appropriate competencies and skill sets to provi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide staff with appropriate competencies and skill sets to provide nursing and related services to ensure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for two sampled residents (Resident #1 and #2) when staff failed to implement interventions preventing Resident #2 from hitting Resident #1 and interventions preventing staff from physically moving Resident #1 against his/her will. The census was 120.
On 02/25/25 at 3:30 P.M., the Administrator was notified of the immediate jeopardy (IJ) which began on 02/06/25. The IJ was removed on 02/27/25, as confirmed by surveyor onsite verification.
The facility did not provide a policy regarding the unit staffing needs or specialized training needed to work on a locked behavior unit.
The facility did not provide a documented mental health behavior training program for all staff including temporary agency staff working on the secured behavioral unit.
1. Review of Resident #1's Preadmission Screening and Resident Review (PASRR), dated 07/27/23, showed:
- A 50 plus years of mental illness with no family support;
- Impaired judgement and decision making;
- A long history of psychiatric treatments;
- Required a secured behavioral unit.
Review of Resident #1's face sheet showed:
- Had a Public Administrator as a guardian;
- Diagnoses of Schizoaffective Disorder-Bi Polar type (a mental health disorder involving depression, hallucinations and delusions with bouts of manic behavior), and heart failure.
Review of Resident #1's annual Minimum Data Set ((MDS) a federally mandated assessment instrument completed by the facility staff) dated, 01/29/25, showed:
- The resident was cognitively intact;
- The resident refused care and physically disrupts the environment on a daily basis;
- The resident triggered for delirium (confused thinking, agitation and memory problems), cognitive loss, and falls.
Review of Resident #1's Care Plan, dated 03/05/25, showed:
- The resident required supervision with all activities of daily living (ADLs);
- The resident had a history of aggression and throwing urine on others;
- The resident had impaired cognitive thought processes;
- The resident resided on a secured behavior unit until 02/06/25;
- The resident may exhibit behaviors such as throwing himself/herself onto the floor when he/she does not get their way. Interventions included Social Services working with the resident one on one, staff redirecting resident when he/she is impatient and remind the resident of his/her coping skills when he/she is angry;
- The resident has a history of elopement attempts from the locked unit. Interventions included staff will accompany the resident to and from destination if the resident needs to be off the locked unit, staff will notify the resident's psychiatric doctor and resident will be put on one on one monitoring or 15 minute checks to ensure safety;
- The resident is resistive to care and treatments at time. Interventions included allowing resident time to make decisions and explaining processes slowly and leaving the situation and coming back 5-10 minutes later and approach again.
Review of Resident #2's PASRR, dated 04/07/22, showed the resident meets requirements for short term nursing facility placement. The resident required:
- A behavioral support plan;
- A structured environment;
- Crisis intervention services;
- Discharge planning;
- Medication therapy and monitoring;
- ADL assistance.
Review of Resident #2's face sheet showed:
- Diagnoses of Autistic Disorder (a lifelong disorder affecting how a person communicates, interacts with others and behaves), Schizophrenia (a mental health disease affecting how a person thinks including delusions, paranoia and hallucinations), and delusional disorder (a serious mental illness causing unshakeable false beliefs).
Review of Resident #2's annual MDS, dated [DATE], showed the resident:
- Cognitively intact;
- Exhibited hallucinations (the perception of the presence of something that is not actually there, involving one or more of the five senses, and delusions are fixed, false beliefs not shared by others that the resident holds even in the face of evidence to the contrary) and delusions (a fixed, false belief that the resident holds, even in the face of evidence to the contrary);
- Exhibited physical behaviors (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) one to three day during the 7 day look back observation period;
- Exhibited verbal behaviors (threatening others, screaming at others, cursing at others) one to three days during the 7 observation period;
- The resident's behaviors put others at a significant risk and significantly disrupt the care environment.
Review of Resident #2's care plan, updated 03/05/25, showed:
- On 11/8/24 the resident had a resident to resident altercation and was placed on one on one monitoring. The care plan was updated on 12/10/24 to include the resident has delusions at times and will strike staff and other residents without warning. Interventions included remaining on one on one monitoring, informing the resident's physician of the behaviors and reminding the resident to use his/her coping skills;
- The resident frequently becomes fixated on his/her medication administration and will follow CMTs around. The resident also has a history of hitting staff and staff equipment if he/she does not get his/her medications when he/she asks for them. Interventions included directing CMTs to give Resident #2 his/her medication first on his/her hall of residence and for the resident to seek assistance if he/she can't use his/her coping skills.
Review of Resident #2's Care Plan for Behaviors, dated 11/14/24, showed:
- The resident has a history of delusions with suspicious thoughts and impulsive behaviors which include medication non-compliance, poor hygiene, hitting head when distressed, consumption of non food items (i.e. paint chips), consumption of large quantities of food, rocking, strange postures, staring episodes, and startling easily per level II PASRR.
- The resident also becomes distressed by loud noises, exhibits threatening behavior towards his/her father, fixation on particular items, abnormal thought process, and withdrawn;
- Interventions included:
- Administer medications as ordered;
- Ascertain causes for symptoms;
- Conduct intervention matching causes of symptoms, preferences include music therapy, orientation training, exercise and/or art cognitive activity;
- Observe for effectiveness of medications;
- Offer tea or [NAME] Aid as way to promote calmness;
- Engage conversations with me about my musical preferences;
- Refer resident to activities of choice, like watching TV;
- Engage resident in conversations regarding baseball, or find a game on TV;
- Offer resident his/her PAD. I enjoy playing games/using my PAD;
- Staff will monitor for consumption of non-food items and report any abnormal findings to physician.
Review of the facility's investigation, dated 02/06/25, showed:
- On 02/06/25, Resident #2 asked Certified Medication Technician (CMT) A for medications;
- CMT A informed Resident #2 it was too early for the medications;
- Resident #2 was on one on one with a designated staff member, Certified Nurse Aide (CNA) B, due to a history of aggressive behaviors;
- The resident became agitated and started to walk down the hallway;
- CMT A was afraid of Resident #2 and locked himself/herself in a clean linen closet;
- CNA B and Licensed Practical Nurse (LPN) C, followed Resident #2 halfway down the hall and stopped two rooms away;
- Resident #2 went to the end of the hallway and stared into Resident #1's room for a few minutes;
- CNA B and LPN C watched as Resident #2 raised his/her arms up and ran into Resident #1's room. Resident #2 ran into the room and hit Resident #1 on the left side of the head;
- Resident #1 sustained a hematoma to the left side of the head (damaged blood vessels surrounding the tissue).
During an interview on 02/25/25 at 2:00 P.M., CMT A said he/she is agency staff and had been with the facility as needed since July 2024. CMT A said that in the past he/she had received education and training on working with mental health residents. CMT A said on 02/06/25, Resident #2 asked for his/her medications too early. The CMT said he/she told Resident #2 it was not time for his/her medications yet. CMT A said getting his/her medications is a trigger for Resident #2 and he/she became very threatening toward the CMT after he/she told the resident he/she was unable to provide the medications. CMT A said he/she removed himself/herself from the situation by hiding in the closet. CMT A said he/she did not know if CNA B and LPN C would be able to handle Resident #2 if he/she escalated in behaviors, because Resident #2 is large and can be very aggressive. CMT A said he/she hid in hopes to de-escalate the resident by removing himself/herself from the situation quickly. CMT A said he/she peeked out of the closet and saw Resident #2 enter Resident #1's room. CMT A heard Resident #1 yelling for help. LPN C and CNA B stood at least two room doors away and did not attempt to stop Resident #2 from entering Resident #1's room. CMT A said the only intervention in place for Resident #2 was the one on one monitor, other than that he/she would attempt to redirect the resident. CMT A had never seen a care plan for a resident.
During an interview on 02/25/25 at 3:15 P.M., LPN C said CNA B had been assigned to monitor Resident #2 in a one on one capacity due to the resident's history of aggressive behaviors toward other residents. Resident #2 asked CMT A for a medication and CMT A told the resident it was too early. Resident #2 became agitated. When Resident #2 started to walk down the hallway, he/she and CNA B followed. LPN C said they watched Resident #2 standing at the doorway to Resident #1's room and they stood back down the hall to provide the resident space and not approach him/her. LPN C said they were hoping if Resident #2 had some space he/she would de-escalate. LPN C did not know what interventions Resident #2 was care planned for. They were two rooms behind Resident #2 observing, when Resident #2 ran into Resident #1's room and hit Resident #1. LPN C said he/she and CNA B then ran toward Resident #1's room and stopped Resident #2 from hitting Resident #1 again. LPN C said when Resident #2 had become agitated the staff should have intervened to protect Resident #1 by attempting to redirect Resident #2 away from Resident #1's room. LPN C said he/she had received training on de-escalating a resident. LPN C did not say why he/she did not intervene and attempt to de-escalate Resident #2 before he/she struck Resident #1. LPN C said he/she did not try to engage Resident #2 in any conversation about his/her favorite things or other interventions from the resident's behavioral care plan.
During an interview on 02/25/25 at 4:20 P.M., CNA B said he/she is an employee of the facility and not agency staff. CNA B said he/she had been assigned to monitor Resident #2 one on one, on 2/06/2025 due to the resident's history of hitting other residents in the head. Resident #2 was agitated due to not getting the medication he/she requested. Resident #2 started down B Hall while he/she and LPN C followed, but not too closely. He/she said they stood about two rooms away hoping Resident #2 would step back and away from Resident #1's room. CNA B said Resident #2 stood at the doorway of Resident #1's for awhile then raised his/her arms and took off toward Resident #1 striking him/her in the head. CNA B said he/she and LPN C then ran toward Resident #1's room and heard him/her screaming. They intervened and stopped Resident #2 from striking the resident again. He/she did not say why they were not closer to Resident #1. CNA B said he/she had received training on redirection and de-escalation, but did not use any verbal redirection with Resident #2. CNA B did not say why he/she or LPN C did not attempt to stop Resident #2 from striking Resident #1 the first time nor did he/she say why he/she did not attempt any of the interventions listed in the care plan.
During an interview on 02/25/25 at 9:45 A.M., the Administrator (ADM) said facility staff receive training on de-escalation methods twice monthly. However, the facility currently has in house staffing issues and rely on agency staff. The ADM said he cannot force agency staff to participate in facility training. The ADM said they have invited the agency staff to all trainings, but they do not come. He said that he had called the agency to see if they could be made to attend and no one returned the call. He would expect all staff to protect the residents. The ADM said he expected the staff, CNA B and LPN C, to have stopped Resident #2 from hitting Resident #1. CNA B and LPN C are not agency staff and should have called for assistance if they felt they could not handle Resident #2. The ADM said on 02/06/25, Resident #2 was already being monitored one on one for previous aggressive behaviors. He was unsure what other interventions were in place for Resident #2. The ADM said they were doing the best they could, but staff seemed to be scared of Resident #2. The ADM said he was unsure how care plan information was shared with staff.
2. Review of the facility's investigation, dated 02/08/25, showed:
- Resident #1 was removed from the B Hall after an incident involving Resident #2;
- Resident #1 did not want to leave B Hall and went back to B Hall during the evening hours to go to his/her old room;
- Staff members LPN D and CNA E approached the resident and attempted to get Resident #1 redirected to his/her new hall;
- Resident #1 sat in the floor and refused to get up;
- Resident #1 continued to refuse to leave the B hall and laid in the floor while staff attempted to pull him/her to a standing position;
- LPN D then placed a blanket on the floor and physically rolled Resident #1 onto the blanket;
- LPN D and CNA E dragged the blanket and Resident #1 on the floor down B hall, through the lobby to his/her new room on A Hall.
During an interview on 3/6/2025 at 10:20 A.M., CNA E said he/she was an agency staff member. CNA E said prior to arriving at the facility, he/she had no idea he/she would be assigned to a behavior hall. CNA E said he/she did not know the names of any other staff. He/she received no training or policies on the Behavior Hall, a secured unit. During the evening, Resident #1 came onto the B hall and said his/her room was there. The other staff members on the hallway told the resident that he/she needed to return to the A hall where the resident had been relocated to earlier that day. The resident sat on the floor and wanted to remain there. The resident was not causing any problems or having any behaviors. The resident did refuse to go to his/her new room and was wanting to return to the old room he/she had been in prior to the relocation. The charge nurse, LPN D, came to the B hall and told the resident he/she had to leave. CNA E said he/she requested multiple times to allow the resident to just remain on the floor and calm down and then redirect. LPN D got a blanket to put on the floor, rolled the resident onto the blanket and instructed CNA E to grab a corner and pull. LPN D drug the resident through the hallway to the A hallway.
During an interview on 3/6/2025 at 11:30 A.M., LPN D said he/she was agency staff brought in with no information regarding working a behavior unit. He/she was not given any policies or protocols, and did not have time to become familiar with residents prior to starting job duties. LPN D did not know Resident #1 had only been moved earlier that day and did not know the resident was at risk for elopement. On 02/06/2025 Resident #1 left his/her current hall and entered B hall. Staff from B hall called him/her to assist with Resident #1. Resident #1 was sitting in the hallway asking to go in his/her old room. Staff on B hall, unknown to LPN D, were attempting to get the resident to stand up and the resident laid in the floor. LPN D said he/she tried to redirect. The B hall staff said the resident had been attacked earlier by another resident who still was on B hall and it was not safe for Resident #1 to be there. LPN D said he/she attempted to reach the facility's Director of Nurses and on call staff and no one answered. He/she decided that the resident needed to be moved to ensure his/her's safety. He/she used the fireman blanket transfer (a blanket used to transfer people in emergency situations safely) to move the resident safely. The resident was rolled onto the blanket. LPN D then had CNA E assist in dragging the blanket from the unit on Hall B, through the lobby to A hall. The resident was anxious and appeared nervous, after being drug through the facility but was not yelling or being aggressive. LPN D felt it was the only way to ensure the resident was safe.
During an interview on 02/25/25 at 9:45 A.M., the ADM said the facility currently has in house staffing issues and rely on agency staff. The facility has requested the agency staff to attend in-servicing but they have in the past refused. The two staff who put Resident #1 on a blanket and drug him/her through the facility were agency staff. The ADM did not know how their policies were communicated to agency staff. The ADM said in this situation, he would expect staff to attempt to redirect and if not possible to sit with the resident until they calm down.
Complaint #MO249378
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
Dec 2024
13 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This had the potential to affect all residents. The facility's c...
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Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This had the potential to affect all residents. The facility's census was 115.
Review of the facility's policy, Maintenance Repair Policy, dated 08/24/24, showed:
- All team members are orientated to the Maintenance Work Order log located at each nurses' station;
- Any team member can complete the Maintenance Work Order;
- Maintenance personnel shall address routine maintenance work orders throughout the day, within 24 hours, or the next business day;
- Emergency work orders shall be addressed upon notification;
- In the event a work order has not been addressed within the timeframe specified, any team member will contact the Maintenance Director;
- A log of these work orders shall be retained by the Maintenance Director;
- In the event the Maintenance Director is unavailable, all concerns should be directed to the Administrator.
Observations on 12/01/24 at 1:30 P.M. of the main entrance common area showed an overwhelming urine odor.
Observation on 12/01/24 at 4:55 P.M. showed numerous brown stains on ceiling tiles on C hall near the nurses station and fire doors.
Observations on 12/01/24 at 5:00 P.M. of the D hall common area showed:
- A missing ceiling tile with exposed wires by the exit to the men's unit;
- Eight missing ceiling tiles over the nurse's station showing exposed wires and duct work;
- Large brown stains on the remaining ceiling tiles over the nurse's station;
- Dirt and debris in the large vented tiles in the corner of the ceiling opposite of the door to the men's unit;
- [NAME] stains and chipped tiles throughout the common area ceiling in unit D.
During an interview on 12/01/24 at 4:53 P.M., Resident #30 said he/she has lived here three years and the owner won't fix the leaking roof. Staff have to put buckets in the hall to catch the water.
During an interview on 12/01/24 at 5:15 P.M., Resident #8 said it bothered him/her that there were missing ceiling tiles and exposed wires in the common area of unit D.
During an interview on 12/02/24 at 3:27 P.M., the Maintenance Director said the facility will be getting a new roof hopefully before the end of this week. He/she had not replaced the tiles yet because he/she wanted to wait until the new roof is installed.
During an interview on 12/06/24 at 3:45 P.M., the Administrator said they are in the process of getting a new roof and they planned to replace the ceiling tiles once the new roof is installed.
Complaint #MO00245882
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #12 and #96) were free...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #12 and #96) were free from physical abuse when one resident (Resident #27) struck Resident #12 on the right side of the face and later that day, struck Resident #96 in the face. The facility's census was 137.
Review of the facility's Abuse, Neglect and Exploitation Policy, updated 04/08/24, showed:
- Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion;
- Resident must not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident family members, legal guardians, friends or other individuals;
- Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish;
- Physical Abuse includes, but is not limited to hitting, slapping, pinching and kicking;
- When suspicion or reports of abuse, neglect or exploitation, it must be communicated to the facility's Administrator, Department Head, or Supervisor, and the Administrator and/or designee must initiate an investigation;
- Once the resident is cared for and initial reporting has occurred, an investigation should be conducted including interviewing the involved resident, interview witnesses separately, document investigation chronologically;
- The facility will make efforts to protect any and all residents after alleged abuse, neglect, and/or exploitation.
1. Review of Resident #27's medical record showed:
- admitted on [DATE];
- Diagnoses of epilepsy (seizure disorder), hallucinations and schizoaffective disorder;
- Cognitively intact;
- Supervision with ADLs.
Review of Resident #27's Care Plan showed:
- Lives in supervised environment;
- Independent of ADLs with supervision;
- Behaviors of physical aggression, altered mental status after seizure activity, poor impulse control;
- Legal guardian.
Review of Resident #27's Preadmission Screening and Resident Review (PASRR) Level II, dated 02/22/20, showed:
- Psychiatric assessment history of schizoaffective disorder (bipolar type), impulse control and anxiety;
- Needs can be met in nursing facility.
Review of Resident #27's Progress Notes showed:
- On 11/27/24 at 9:31 A.M., reported that Resident #12 was sitting in a chair, in the hall outside of the nurse's station;
- Resident #27 approached resident and struck him/her to the right side of his/her face/head;
- Residents were separated and evaluated for injuries;
- On 11/27/24 at 3:30 P.M., reported to nurse by personnel providing 1:1 supervision to Resident #27, that Resident #27 was ambulating down hall;
- Resident #96 witnessed speaking to himself/herself, which agitated Resident #27;
- Resident #27 struck Resident #96 in mouth;
- Residents were separated and assessed for injuries. No injuries noted;
- Resident #27's 1:1 personnel remained with him/her;
- Provider, guardian notified and new orders to send for psychiatric evaluation;
- Resident #27 departed facility willingly with police escort and emergency medical services.
Review of written statement on 11/27/24 from Certified Nursing Assistant (CNA) M showed:
- Resident #27 was walking toward activity room and saw Resident #96 sitting in corner, talking to himself/herself and making hand gestures;
- Resident #27 ran up to Resident #96, punched him/her in the face;
- CNA M yelled for nurse who arrived promptly.
2. Review of Resident #12's medical record showed:
- admitted on [DATE];
- Diagnoses of schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs), and symptoms may include delusions, hallucinations, depressed episodes, and manic periods of high) and dementia (thinking and social symptoms that interfere with daily functioning);
- Cognitively intact;
- Supervision with activities of daily living (ADLs).
Review of Resident #12's Care Plan showed:
- Needs 24 hour oversight due to poor sight and judgment;
- Supervision with ADLs;
- Has a legal guardian.
Observation on 12/01/24 at 7:50 P.M. showed Resident #12 with a fist-sized bruise on his/her right lower cheek/jaw area.
Review of Resident #12's Progress Notes showed:
- On 11/27/24 at 8:55 A.M., Resident #12 was sitting in the hall in a chair outside of the nurses' office;
- Resident #27 went up to Resident #12 and struck him/her on right side of his face and head;
- Scratch mark noted to Resident #12's right upper lip;
- Resident #12 reported 8/10 pain;
- Providers, administration, and guardians notified;
- Order obtained to send out for further evaluation.
Review of Resident #12's hospital record showed:
- On 11/27/24 at 9:58 A.M., family notified of hospital visit and plan of care;
- Resident #12 refused diagnostic imaging;
- Diagnosed with contusion (bruise) to face and injury of head;
- Continue current medications.
Review of the investigation for Resident #12 and #27, dated 11/27/24 at 9:00 A.M., showed:
- Resident #12 was sitting in hallway on secured B hall when Resident #27 overheard Resident #12 speaking loudly to self;
- Resident #27 thought Resident #12 was yelling at him/her, so he/she struck him/her;
- Both residents were sent out for evaluation and medical clearance;
- Resident #12 returned with no new orders, and neurological checks were started for 72 hours;
- Resident #27 placed 1:1;
- Care plans updated and responsible parties notified.
Review of written statement from Certified Medication Technician (CMT) P, dated 11/27/24, showed:
- Resident #12 was sitting outside of nurses station;
- Resident #27 struck Resident #12 on the right side of his/her face;
- Both residents were sent out separately to hospital for check up.
3. Review of Resident #96's medical record showed:
- admitted on [DATE];
- Diagnoses of bipolar disorder, schizophrenia, delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness in surroundings) and paranoid personality disorder (a disorder characterized by paranoia, suspiciousness and mistrust of others);
- Significantly impaired cognitively;
- Supervision with ADLs.
Review of Resident #96's Care Plan showed:
- Lives in supervised environment;
- Independent of ADLs with supervision;
- Behaviors of paranoid delusions and threatened physical violence to other resident.
Review of Resident #96's PASRR Level II, dated 06/16/23, showed:
- Psychiatric assessment history of paranoid schizophrenia, psychotic disorder, bipolar disorder;
- Needs can be met in nursing facility.
Review of Resident #96's progress notes showed:
- On 11/27/24 at 5:26 P.M., (late entry), reported that Resident #96 was struck by Resident #27;
- Resident #96 refused hospital and vital signs;
- No injuries noted during assessment;
- Guardian, provider and administration notified.
Review of the investigation for Resident #27 and Resident #96, dated 11/27/24 at 3:30 P.M., showed:
- Resident #96 was sitting in dayroom on secured B hall;
- Resident #27 was walking down hall with his/her 1:1;
- Resident #96 was waving hands in the air as Resident #27 walked by and Resident #27 hit Resident #96 in the face;
- Staff immediately separated both residents;
- Resident #96 refused to be assessed or go to hospital, however, neuro checks were started;
- Nurses noted no injuries to either resident;
- Resident #27 was sent to hospital for evaluation and later transferred to another hospital for further psych evaluation;
- Resident #27 to be placed 1:1 for 96 hours upon return due to aggressive behaviors;
- Both residents' responsible parties notified and care plans updated;
- Resident #27 had not returned during the survey and licensure process.
During an interview on 12/03/24 at 3:34 P.M., the Administrator said the facility does monthly in-services with staff to educate how to deal with residents and their behaviors. The facility has two nurse practitioners that come to the facility and they try to staff the same staff members in the units because of rapport.
During an interview on 12/05/24 at 11:29 A.M., the Administrator said the Environmental Aides (EAs), have the same behavior training as the rest of staff as far as de-escalation. The EAs are 1:1 due to behaviors or elopement risks. Staff have mandatory in-services twice a month (7th and 27th) on pay day. Staff have to come in and pick up their check and do not receive it until after the in-service has been completed.
During an interview on 12/06/24 at 11:09 A.M., Certified Medication Technician (CMT) P verified his/her statement as it had been written for the investigation and said staff are trained to separate residents when an altercation/behavior occurs, report to the nurse and transfer out as needed. He/She could visibly see a small cut on Resident #12. It bled a little, so the resident was cleaned up and sent to the hospital for evaluation.
During an interview on 12/06/24 at 12:16 P.M., Licensed Practical Nurse (LPN) N said Resident #27 is normally shy and stays in his/her room and to himself/herself. Resident #12 was hit so quick, and then it was over. It was very random. Resident #12 was sent out to the hospital for evaluation, but had refused all scans. The resident had a bruise to his/her right lower face that showed up later.
During an interview on 12/06/24 at 3:45 P.M., the Administrator and Director of Nursing said they would expect residents to be free from abuse. The facility had educated staff, had social service workers on each hall, and provided one on one for residents having issues.
Complaint #MO00245812
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the ombudsman of all transfers to the hospital and failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the ombudsman of all transfers to the hospital and failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for ten residents (Resident #8, #12, #15, #23, #26, #33, #35, #95, #111, and #315) out of 23 sampled residents and two residents (Resident #27 and #216) outside the sample. The facility's census was 115.
Review of the facility's policy, Admission, Transfer and Discharge, revised 08/24/24, showed:
- The facility may transfer or discharge the resident in compliance with facility standards and are as follows, but not limited to: the resident's welfare and needs cannot be met in the facility, the health or safety of individuals in the facility would otherwise be endangered, if the resident's health has improved sufficiently so the resident no longer needs the facility's services, or if the resident fails to pay any charges when due;
- The facility policy does not address the process of notifying responsible parties of transfer notices or notification of the Ombudsman.
Review of the facility's form, Notice of Transfer or Discharge of Nursing Home Resident, undated, showed:
- This nursing facility will take the following steps to ensure a safe and orderly transfer or discharge from the facility (Please check below all that apply): Resident was provided with explanation as to why they were being transferred to the hospital; Copies of resident's Advanced Directives, Face Sheet, Physician's Orders, and any additional documents; Resident was educated about method of transport to the hospital - Facility staff escort or Ambulance; Bed hold policy has been reviewed with/provided to the resident and a copy will be mailed to the resident's legal representative, if applicable, at the time of transfer/discharge from the facility;
- Copy to be sent with resident upon transfer or discharge;
- Copy to be mailed to legal representative by Social Services.
1. Review of Resident #8's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], 02/25/24, 04/24/24, 05/02/24, 05/27/24, 07/13/24, 08/01/24, 08/21/24, 08/27/24, 08/30/24, 09/19/24, 10/01/24, 10/15/24, 10/17/24, 10/24/24, and 11/28/24;
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer;
- Hospital transfers on 02/24/24, 02/25/24, 05/02/24, 05/27/24, 07/13/24, 08/27/24, 08/30/24, 09/19/24, 10/17/24, and 11/28/24 not included on the monthly list sent to the ombudsman.
2. Review of Resident #12's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer.
3. Review of Resident #15's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer;
- Hospital transfers on 09/05/24, 09/24/24, and 10/26/24 not included on the monthly list sent to the ombudsman.
4. Review of Resident #23's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer;
- Hospital transfers on 06/01/24, 06/25/24, and 10/16/24 not included on the monthly list sent to the ombudsman.
5. Review of Resident #26's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer;
- Hospital transfer on 02/06/24 not included on the monthly list sent to the ombudsman.
6. Review of Resident #27's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], 04/24/24, 07/9/24, 07/26/24, 07/29/24, 08/18/24, 08/25/24, 09/24/24, 11/01/24, 11/18/24, 11/27/24 and 12/01/24;
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer;
- Hospital transfers on 01/19/24, 04/24/24, 07/09/24, 07/29/24, 08/18/24, 08/25/24, 09/24/24, 11/01/24, and 11/18/24 not included on the monthly list sent to the ombudsman.
7. Review of Resident #33's medical record showed:
-The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
-The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer.
8. Review of Resident #35's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], 06/01/24, 07/06/24, 07/23/24, 07/29/24, 08/23/24, 09/15/24, 09/20/24, 09/22/24, 10/23/24, 10/27/24, 11/05/24, 11/06/24;
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer;
- Hospital transfers on 05/01/24, 06/01/24, 07/06/24, 07/23/24, 07/29/24, 08/23/24, 09/15/24, 09/20/24, 10/23/24, 10/27/24, and 11/05/24 not included on the monthly list sent to the ombudsman.
9. Review of Resident #95's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to facility on 09/04/24;
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer.
10. Review of Resident #111's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer;
- Hospital transfer on 10/17/24 not on monthly list sent to the ombudsman.
11. Review of Resident #216's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer.
12. Review of Resident #315's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned the same day;
- No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer;
- Hospital transfer on 11/30/24 not included on the monthly list sent to the ombudsman.
During an interview on 12/05/24 at 10:17 A.M., Resident #27's guardian said the facility would call and tell him/her when a resident is being sent out. He/She would sign a transfer form if they would have received it, but he/she had only been giving verbal consent.
During an interview on 12/05/24 at 10:27 A.M., Resident #8's guardian said he/she is on the phone daily with the facility about Resident #8. The facility will notify him/her by phone any time Resident #8 is sent out to the hospital. However, he/she does not ever receive written notification regarding Resident #8's hospital transfers.
During an interview on 12/04/24 at 2:18 P.M., the Administrator said she doesn't have any proof that transfer notifications were sent out to public administrators, guardians, responsible parties, or emergency contacts.
During an interview on 12/05/24 at 10:36 AM, Resident #95's deputy public administrator said transfers and discharges are verbal notification. He/She does not receive written documentation from this facility.
During an interview on 12/05/24 at 2:10 P.M., the Administrator said that the Ombudsman is notified via fax monthly of all discharges from the facility.
During an interview on 12/06/24 at 3:45 P.M., the Administrator and Director of Nursing (DON) said that they would expect all residents that are discharged , including emergency room (ER) visits, to have a transfer form filled out completely, signed, and sent to the responsible party and ombudsman.
During an interview on 12/11/24 at 2:03 P.M., the Admissions Director said she checks with the nurses every morning to see which residents have been in and out and she does her morning census. She has master copies of the Notice of Transfer that she keeps at the nurses' stations and it has the bed hold policy on the back. When the residents go out, the nurses just have to give them to her and she keeps them in a binder. It's the nurses' job to notify families, guardians, or public administrators. Once a month, she faxes a list to the ombudsman's office. She does not send ER transfers on the list, only residents who have been discharged completely, or overnighters, those residents who have been out overnight. She said someone at the ombudsman's office told her a couple years ago not to include residents who go to the ER on the list.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for nine residents (Resident #12, #15, #17, #23, #26, #33, #95, #111, and #315) out of 23 sampled residents, and three residents (Resident #5, #84, and #216) outside the sample. The facility's census was 115.
Review of the facility's policy titled, Bed Hold Policy, undated, showed:
- It is the policy of this facility to notify the resident/responsible party of the bed hold policy. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave;
- The facility agrees to allow the resident to return to the facility at any time during the bed hold period, provided the facility can meet the resident's needs;
- According to state regulations, a resident agreeing to the bed hold policies will have their bed held up to 10 days. Bed hold is voluntary; if a resident chooses to not hold their bed and their bed is not available when they choose to return to the facility and wants to be re-admitted , the resident's name will be placed on a waiting list for the next available bed.
Review of the facility's form, Notice of Transfer or Discharge of Nursing Home Resident, undated, showed:
- This nursing facility will take the following steps to ensure a safe and orderly transfer or discharge from the facility: Bed hold policy has been reviewed with/provided to the resident and a copy will be mailed to the resident's legal representative, if applicable, at the time of transfer/discharge from the facility.
1. Review of Resident #5's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
2. Review of Resident #12's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
3. Review of Resident #15's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
4. Review of Resident #17's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
5. Review of Resident #23's medical record showed:
-The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
-The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
-The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
-The resident transferred to the hospital on [DATE] and returned to the facility on [DATE].
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
6. Review of Resident #26's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
7. Review of Resident #33's medical record showed:
-The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
8. Review of Resident # 84's medical record showed:
- admitted on [DATE];
- The resident was transferred to the hospital on [DATE] and returned to the facility the same day;
- The resident was transferred to the hospital on [DATE] and returned to the facility the same day;
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
9. Review of Resident #95's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to facility on 09/04/24;
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
10. Review of Resident #111's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
11. Review of Resident #216's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE];
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
12. Review of Resident #315's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE] and returned to the facility the same day;
- No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer.
During an interview on 12/04/24 at 2:18 P.M., the Administrator said she doesn't have any proof that bed hold policies were sent out to public administrators, guardians, responsible parties, or emergency contacts.
During an interview on 12/05/24 at 10:36 AM, Resident #95's deputy public administrator said transfers and discharges are verbal. He/She does not receive written documentation from this facility.
During an interview on 12/06/24 at 3:45 P.M., the Administrator and Director of Nursing (DON) said they would expect all residents that are discharged , including emergency room (ER) visits, to have a bed hold/transfer form filled out completely, signed, and sent to the responsible party and Ombudsman.
During an interview on 12/11/24 at 2:03 P.M., the Admissions Director said she checks with the nurses every morning to see which residents have been in and out and she does her morning census. She has master copies of the Notice of Transfer that she keeps at the nurses' stations and it has the bed hold policy on the back. When the residents go out, the nurses just have to give them to her and she keeps them in a binder. It's the nurses' job to notify families, guardians, or public administrators.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for two re...
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Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for two residents (Resident #33 and Resident #57) out of 23 sampled residents and one resident (Resident #113) outside the sample. The facility's census was 115.
Review of the facility's policy titled, MDS Policy, revised 08/02/24, showed:
- Purpose: In Medicare, MDS stands for Minimum Data Set. It's a federally mandated process that involves a standardized assessment of each resident's health and functional capabilities in nursing homes certified by Medicare and Medicaid. The MDS assists nursing home staff identify health issues and potential problems, strengths, and preferences for residents. The assessment is completed electronically and transmitted to the state;
- Procedure: The Resident Assessment Instrument (RAI) Manual serves as the policy by which the facility follows the process of completing MDS assessments.
Review of the RAI Manual, revised October 2024, showed:
- A significant change in status (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident;
- An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The Assessment Reference Date (ARD) must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill;
- The ARD must be less than or equal to 14 days after the Interdisciplinary Team (IDT)'s determination that the criteria for a significant change in status assessment (SCSA) are met (determination date + 14 calendar days);
- The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met.
1. Review of Resident #33's medical record showed:
- An admission date of 09/12/24 to hospice services;
- The facility failed to complete a significant change MDS assessment within 14 days of hospice admission.
2. Review of Resident #57's medical record showed:
- An admission date of 05/10/24 to hospice services;
- The facility failed to complete a significant change MDS assessment within 14 days of hospice admission;
- A discharge date of 10/08/24 from hospice services;
- The facility failed to complete a significant change MDS assessment within 14 days of the hospice discharge.
3. Review of Resident #113's medical record showed:
- A discharge date of 05/02/24 from hospice services;
- The facility failed to complete a significant change MDS assessment within 14 days of the hospice discharge;
- An admission date of 05/21/24 to hospice services;
- The facility failed to complete a significant change MDS assessment within 14 days of hospice admission;
- A discharge date of 05/22/24 from hospice services;
- The facility failed to complete a significant change MDS assessment within 14 days of the hospice discharge;
- An admission date of 06/10/24 to hospice services;
- The facility failed to complete a significant change MDS assessment within 14 days of hospice admission.
During an interview on 12/05/24 at 11:18 A.M., the Administrator said they do not have an MDS Coordinator on site. The facility uses a contracted company. The facility sends the contracted company daily reports and they attend weekly meetings virtually. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) do the assessments and lay eyes on the residents, then send the information to the contracted company for completion of the MDS assessments.
During an interview on 12/06/24 at 3:45 P.M., the Administrator and DON said they would expect a significant change MDS to be completed per the RAI Manual.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for six residents (Resident #9, #23, #33, #56, #57 and #8...
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Based on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for six residents (Resident #9, #23, #33, #56, #57 and #87) out of 23 sampled residents. The facility's census was 115.
Review of the facility's policy titled, Care Plan Policy, reviewed 08/24/24, showed:
- A care plan shall be used in developing the resident's daily care routine and will be available to the team for review to ensure the best person-centered care is provided to our residents;
- A comprehensive care plan will be generated through collaboration with the interdisciplinary team (IT), resident and responsible party, to be completed by the 21st day of admission;
- The care plan will reflect a problem, goal and interventions to guide the IT team to assist the resident in achieving the desired outcome for a specific problem;
- When goals and objectives are not achieved, the resident's medical record will be updated and the care plan will be modified accordingly;
- The care plan will be reviewed quarterly and updated as needed.
1. Review of Resident's #9's medical record showed:
- An admission date of 04/07/24;
- Diagnoses of noninfective gastoenteritis and colitis (inflammation of the stomach or intestines, not caused by infection), placement of ostomy (medical device that collects waste from a surgically diverted system), and chronic viral hepatits C (liver inflammation and damage caused by infection with hepatitis C virus.)
Review of the resident's care plan, initiated 04/20/22, showed the care plan did not address the resident's ostomy.
2. Review of Resident #23's medical record showed:
- An admission date of 05/27/22;
- Diagnoses of chronic obstructive pulmonary disease (COPD - condition caused by damage to the lungs, making it hard to breathe), schizoaffective disorder (mental health condition that can cause hallucinations and delusions with mood disorder), unspecified dementia (condition in which a person loses their ability to think, remember, learn, make decisions and solve problems), and Parkinson's disease (a progressive brain disorder that causes problems with movement, mental health issues and other health concerns);
- Order to admit to hospice services on 08/05/24.
Review of the resident's smoking assessment, dated 11/12/24, showed the resident does not utilize tobacco.
During an interview on 12/02/24 at 1:30 P.M., Resident #23 said he/she used tobacco pouches.
Review of the resident's care plan, initiated 06/07/22, showed:
- Resident care planned to use nicotine patches to facilitate smoking cessation;
- Care plan did not address the use of tobacco pouches or hospice services.
3. Review of Resident #33's medical record showed:
- An admission date of 12/10/18;
- Diagnoses of schizoaffective disorder, COPD, and Parkinson's disease;
- Order to admit to hospice services on 09/12/24.
Review of the resident's care plan, initiated 04/04/20, showed the care plan did not address hospice services.
4. Review of Resident #56's medical record showed:
- An admission date of 11/14/22;
- Diagnoses of secondary Parkinsonism (tremors, stiffness, slow movements caused by underlying medical condition or external factors), Alzheimer's/dementia (decline in mental abilities that impact daily life), and severe protein calorie malnutrition (critical deficiency in both protein and calories in the diet, leading to significant muscle wasting, loss of body fat and impaired bodily functions);
- Order for a pureed diet with thin liquids, dated 07/09/24.
Review of the resident's care plan, start date 04/05/24, showed:
- Regular diet;
- Care plan did not address diet change to pureed diet with thin liquids on 07/09/24.
5. Review of Resident #57's medical record showed:
- An admission date of 03/31/23;
- Diagnoses of muscle wasting and atrophy (loss of muscle tissue and strength), retention of urine (difficulty urinating and emptying the bladder), and Alzheimer's disease (decline in mental abilities that impact daily life);
- No Physician's order to admit or discharge from hospice services;
- No Physician's order for foley catheter (a tube inserted into the bladder to drain urine);
- No Physician's order to change foley catheter.
Review of the resident's care plan, initiated 05/01/23, showed:
- Care plan did not address the resident's foley catheter;
- Did not address the resident was receiving hospice services; admitted to hospice services on 05/10/24 and discontinued hospice services 10/08/24 per Administrator.
6. Review of Resident #87's medical record showed:
- An admission date of 08/16/22;
- Diagnoses of Parkinson's disease, encephalopathy (a broad term for any brain disease that alters brain function or structure), and schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves);
- Order to admit to hospice services on 11/07/24.
Review of the resident's care plan, initiated 10/18/22, showed care plan did not address hospice services.
During an interview on 12/05/24 at 11:51 A.M., the Corporate Nurse/Infection Preventionist (IP) said that a contract company updates the care plans, along with Social Services and the Director of Nursing (DON).
During an interview on 12/06/24 at 3:45 P.M., the Administrator and DON said they would expect care plans to be accurate and reflect the current condition of the resident and that care plans should be revised as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Resident #8, #15, #20, and #57) out of 23 sampled residents and one resident (Resident #5) outside the sample. The facility's census was 115.
Review of the facility's policy titled, Physician Orders, updated 08/24/24, showed:
- The purpose of this policy is to ensure our residents receive the care prescribed by their physician;
- Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Medication Technicians (CMTs) are expected to review orders prior to administering medications and/or performing a treatment;
- The RNs, LPNs, and CMTs are to follow the orders as written.
Review of the facility's document titled, Scale/Weights Action Timeline, undated, showed on September 11, 2024, temporary scales purchased. All non-wheelchair bound residents weighed.
1. Review of Resident #5's medical record showed:
- admitted on [DATE];
- Diagnoses of schizoaffective disorder (a condition including schizophrenia and other mood disorder) and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life.)
Review of the resident's Physician's Order Sheet (POS), dated 12/06/24, showed:
- Order for daily blood pressures, starting on 08/06/24;
- No documented blood pressures for 102 out of 124 days.
2. Review of Resident #8's POS, dated 12/06/24, showed:
- Check monthly weights and record;
- Lithium Carbonate Oral Capsule (a mood stabilizer) 600 milligram (mg), started 01/04/24 and discontinued 08/27/24;
- Lithium Carbonate Oral Capsule 600 mg started 08/28/24 and discontinued 10/29/24;
- Lab Draw Lithium Level Every 6 months (183 Days) started 03/31/24 and discontinued 08/27/24;
- Lab Draw Lithium Level Every 6 months (183 Days) started 08/27/24 with no end date.
Review of the resident's medical record showed:
- admitted on [DATE];
- Diagnoses of type 2 diabetes (a condition where the body has trouble controlling blood sugar), major depressive disorder (mental health disorder with persistent depressed mood), and undifferentiated somatoform disorder (physical symptoms can't be explained causing loss of appetite, fatigue and gastrointestinal problems);
- No lab draw for lithium levels during the ten months the resident was on lithium.
Review of the Monthly Weight Report, dated 12/01/24, showed no weight for the month of September and October.
3. Review of Resident #15's POS, dated 12/06/24, showed:
- Order for Complete Metabolic Profile (CMP - a routine blood test that measures several key substances in the body to assess overall health and detect potential medical conditions) and Complete Blood Count (CBC - a routine blood test that provides information about the various cells in the blood) every three months, dated 10/07/23 with a start date of 03/20/24;
- Order to check vital signs and weights monthly and record, dated 04/23/21.
Review of the resident's medical record showed:
- admitted on [DATE];
- Diagnoses of bipolar disorder (a mental illness that causes extreme shifts in mood, energy, activity, and concentration) and hyperlipidemia (abnormally high levels of fats in the blood);
- CMP and CBC not drawn until 05/06/24, then again on 09/25/24, and 09/30/24.
Review of the resident's Prescriber Recommendation, dated 10/21/24, showed:
- Resident is receiving carbamazepine (CBZ - a medication to treat seizures, nerve pain, and bipolar disorder) and atorvastatin (cholesterol medication) and has not had a lipid panel or CBC level drawn;
- Order carbamazepine level now and every six months thereafter and lipid panel now and annually;
- Order for labs not in chart and no lab work provided.
Review of the Monthly Weight Report, dated 12/01/24, showed no weight for the month of October.
4. Review of Resident #20's medical record showed:
- admitted on [DATE];
- Diagnoses of type II diabetes mellitus and schizophrenia (a chronic mental illness characterized by significant disruptions in thought processes, perceptions, emotions, and social interactions.)
Review of the resident's POS, dated 12/04/24, showed:
- Order to check Hemoglobin A1C every three months, dated 09/07/23;
- Order to check vital signs and weights monthly and record, dated 08/09/22.
Review of the resident's lab results showed:
- Hemoglobin A1C labs drawn on 03/13/24 and 07/12/24;
- No Hemoglobin A1C labs drawn prior to 03/13/24 or since 07/12/24.
Review of the Monthly Weight Report, dated 12/01/24, showed no weight for the month of October.
Review of the resident's Medication Regimen Review (MRR) Prescriber Recommendation, dated 11/15/24, showed:
- Resident is receiving oxcarbazepine (seizure medication), paliperidone (antipsychotic medication), metformin (diabetes medication), atorvastatin (cholesterol medication), and levothyroxine (thyroid medication) and has not had labs evaluated;
- CMP and CBC now and every six months thereafter and lipid panel (a blood test that measures the levels of various fats in the bloodstream) and TSH (a blood test that measures the level of thyroid-stimulating hormone in the bloodstream) now and annually thereafter;
- Verbal Order (VO) documented with staff initials beside it.
Review of the resident's medical record showed:
- No order for CMP, CBC, lipid panel, or TSH labs;
- No lab results documented.
5. Review of Resident 57's medical record showed:
- admitted on [DATE];
- Diagnoses of muscle wasting and atrophy (loss of muscle mass and strength), Alzheimer's disease (brain disorder that causes a gradual decline in memory and thinking skills, leading to the inability to do everyday tasks), and retention of urine (a condition where a person is unable to empty their bladder.)
Review of the resident's POS, dated 12/04/24, showed:
- No order to admit to hospice services. Resident was admitted to hospice on 05/10/24 per Administrator;
- Foley catheter (a tube inserted into the bladder to drain urine) care every shift; order dated 10/17/24-12/04/24. Foley discontinued on this date;
- No order to change foley catheter.
Observation of Resident #57 showed:
- On 12/02/24 at 9:30 A.M., the resident lay in his/her bed with a foley catheter attached to the side of the bed;
- On 12/03/24 at 11:00 A.M., the resident lay in his/her bed with a foley catheter attached to the side of the bed.
During an interview on 12/06/24 at 3:45 P.M., the Administrator and Director of Nursing (DON) said they would expect residents to have orders for special programs and treatments, and for the physician's orders to be followed. They would expect residents with a catheter to have orders to change the catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an ongoing program of activities to meet the interests and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an ongoing program of activities to meet the interests and physical, mental, and psychosocial well-being of each resident. This practice affected three residents (Resident #8, #15, and #111) out of 23 sampled residents and four residents (Resident #5, #67, #82, and #102) outside the sample, and had the potential to affect all residents in the facility. The facility's census was 115.
Review of the facility's Activities Policy, reviewed 08/24/24, showed:
- The purpose is to ensure that all residents of the facility have access to meaningful and engaging activities that enhance their quality of life, meet individual needs, and comply with state and federal regulations, including the Centers for Medicare & Medicaid Services (CMS) regulations;
- The facility is committed to providing a comprehensive, person-centered activity program that promotes physical, mental, emotional, and social well-being for all residents. Activities will be designed to respect the residents' preferences, abilities, and cultural backgrounds while fostering community engagement and a sense of purpose. Activities will have an interdisciplinary approach which includes the staff, resident, family, and friends;
- An initial Activity Assessment for each resident will be completed within seven days of admission, with change in condition, and annually;
- Assessment will take into consideration the residents' physical abilities, cognitive status, interests, cultural backgrounds, and past hobbies;
- A personalized care plan will include their preferences and activity goals;
- A variety of activities will be provided addressing different domains: physical, cognitive, social, emotional/spiritual;
- Activities will be adapted for residents with specific needs, including those with dementia, limited mobility, etc. Special accommodations will be made for any resident who requires assistance and/or special accommodations to attend a group activity;
- For residents who prefer not to attend group activities, a 1:1 activity program will be developed with the resident to meet their needs;
- Residents have the right to choose which activities to participate in.
Review of the Resident Council Meeting Minutes, dated November 2024, showed residents suggested doing more karaoke, cookie decorating, and using clay.
Review of the facility's 2024 Activity Calendars showed:
- The September activities calendar had no activities scheduled on the weekends;
- The November activities calendar only had activities scheduled on the first weekend;
- The December activities calendar only had weekend activities scheduled on 12/01, 12/14, and 12/15.
1. Review of Resident #5's medical record showed:
- An admission date of 12/11/23;
- Diagnoses of schizoaffective disorder (a condition including schizophrenia and other mood disorder) and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life.)
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 12/22/23, showed:
- Vision adequate with corrective lenses;
- Moderate cognitive impairment;
- Very important activities included being around animals such as pets and getting fresh air when the weather is good;
- Somewhat important activities included music and doing things with groups of people and doing his/her favorite activities.
Review of the resident's care plan, revised 03/15/24, showed:
- Resident says he/she has impaired visual function related to he/she thinks he/she can not see out of his/her left eye and is supposed to wear glasses;
- Remind the resident to wear glasses when up. Ensure resident is wearing glasses which are clean free from scratches and in good repair. Report any damage to nurse/family;
- Resident will show no decline in visual function through the review date;
- Does not address activities.
During an interview on 12/02/24 at 10:05 A.M., Resident #5 said he/she does not attend the activities because he/she is blind and there are none for him/her. The facility was going to get him/her some books on tape, but he/she didn't know when that was going to happen. He/she has no activities to meet his/her needs on the care plan.
2. Review of Resident #8's medical record showed:
- An admission date of 01/04/24;
- Diagnoses of schizophrenia (a chronic mental illness characterized by significant disruptions in thought processes, perceptions, emotions, and social interactions) and borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships.)
Review of the resident's admission MDS, dated [DATE], showed:
- No cognitive impairment;
- Somewhat important activities included books, newspapers, magazines, music, and doing things with groups of people;
- Somewhat important to do his/her favorite activities.
Review of the resident's care plan, revised 04/24/24, showed:
- Resident enjoys singing, coloring, and walking;
- Resident will attend activities during the scheduled times, will complete 1:1 activities with social services if needed, and will do activities that he/she enjoys;
- Resident will do activities that he/she enjoys through next review.
During an interview on 12/01/24 at 5:15 P.M., Resident #8 said there was an entire week in November when activities were not provided due to the person in charge being off work. Sometimes the residents on the locked unit aren't able to do the activities on the calendar because the activity will be held out in the main area. The facility does not plan enough for them to do and sometimes what is listed on the calendars will be canceled with no replacement activities held.
3. Review of Resident #15's medical record showed:
- An admission date of 04/03/21;
- Diagnoses of schizoaffective disorder and mild intellectual abilities.
Review of the resident's annual MDS, dated [DATE], showed:
- No cognitive impairment;
- Very important activities included music, animals such as pets, doing things with groups of people, getting fresh air when the weather is good, and doing his/her favorite activities;
- Somewhat important activities included participating in religious services.
Review of the resident's care plan, revised 05/16/24, showed:
- Resident likes to listen to country music;
- Resident will attend Social Services groups and activities when frustrated to help get his/her mind off of things.
During an interview on 12/02/24 at 3:33 P.M., Resident #15 said that there are no activities for younger residents and nothing to do on the weekends.
4. Review of Resident #67's medical record showed:
- An admission date of 09/08/20;
- Diagnoses of legal blindness and type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar.)
Review of the resident's annual MDS, dated [DATE], showed:
- Vision severely impaired;
- Moderate cognitive impairment;
- Very important activities included music, doing his/her favorite activities, and getting fresh air when the weather is good;
- Somewhat important activities included keeping up with the news and doing things with groups of people.
Review of the resident's care plan, revised 08/18/23, showed:
- Resident likes to play bingo with assist from staff and enjoys fresh air;
- Preferred activity is bingo;
- Invite and remind resident of scheduled activities;
- Resident may need assistance/escort to activity functions;
- Resident may need assistance with activities of daily living (ADLs) as required during the activity;
- Resident will maintain involvement in cognitive stimulation, social activities as desired through review date.
During an interview on 12/01/24 at 4:45 P.M., Resident #67 said he/she would like more outside time other than smoke times. He/she is blind and says all he/she does is lay in his/her bed and listen to the TV because there isn't anything else to do. He/she will occasionally play bingo, but would prefer more age-appropriate activities.
5. Review of Resident #82's medical record showed:
- An admission date of 12/21/21;
- Diagnoses of schizoaffective disorder and borderline personality disorder.
Review of the resident's annual MDS, dated [DATE], showed:
- Very important activities included music, doing things with groups of people, getting fresh air when the weather is good, and doing his/her favorite activities;
- Somewhat important activities included books, newspapers, magazines, being around animals such as pets, and participating in religious services.
Review of the resident's care plan, revised 03/06/24, showed:
- Resident participates in all activities;
- Invite the resident to scheduled activities;
- Provide schedule of daily tasks/activities;
- Resident will attend/participate in activities of choice three to five times weekly by next review date.
During an interview on 12/01/24 at 5:49 P.M., Resident #82 said there's nothing to do on the weekends. All we can do is play bingo. There's nothing for the younger residents to do.
6. Review of Resident #102's medical record showed:
- An admission date of 05/15/24;
- Diagnoses of schizoaffective disorder and bipolar disorder.
Review of the resident's admission MDS, dated [DATE], showed:
- No cognitive impairment;
- Very important activities included books, newspapers, magazines, music, doing things with groups of people, doing his/her favorite activities, getting fresh air when the weather is good, and participating in religious services;
- Somewhat important activities included being around animals such as pets and keeping up with the news.
Review of the resident's care plan, revised 05/16/24, showed:
- Resident experiences suspicious and isolated behaviors, isolated himself/herself in his/her room while in the hospital and believes people are setting out to harm him/her. He/She is isolative and defensive, and does not share information openly;
- Encourage the resident to attend activities and social services groups;
- When in an isolative mood, invite the resident out to activities/socials. Invite the resident to socialize in small groups with familiar faces;
- Encourage the resident to participate in activities of choice. Facilitate attendance as required;
- Resident will show evidence of adjustment to nursing home by eating in dining room, attending some activities, through next review date.
During an interview on 12/02/24 at 3:43 P.M., Resident #102 said there is not much to do at the facility, so he/she sleeps a lot to pass the day.
7. Review of Resident #111's medical record showed:
- admission date of 10/02/24;
- Diagnoses of schizoaffective disorder and bipolar disorder.
Review of the resident's care plan, revised 10/10/24, showed:
- Create a homelike environment for the resident;
- Encourage the resident to attend activities and groups;
- Resident will be satisfied with his living environment throughout the review period.
Review of the resident's admission MDS, dated [DATE], showed:
- No cognitive impairment;
- Very important activities included books, magazines, newspapers, music, doing his/her favorite activities, and getting fresh air when the weather is good;
- Somewhat important activities included doing things with groups of people.
During an interview on 12/03/24 at 12:53 P.M., Resident #111 said there's nothing to do here. He/She stays in his/her room and keeps to himself/herself. He/She does have a few books to read.
During an interview on 12/06/24 at 1:00 P.M., the Activities Director said there are no activities for residents with special needs or sensory issues. If a bedbound resident asks, then the activity director will do one-on-one activities with him/her. Activities should be on residents' care plans, but he/she has only been in the current role for one and a half months and is behind on getting those entered. A Social Services Designee is typically the one to enter activity preferences into the MDS.
During an interview on 12/06/24 at 3:45 P.M., the Administrator and Director of Nursing (DON) said they would expect there to be activities available for all residents, including those with special needs, accommodations, and interests and activities available on weekends.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) or contraindication for a GDR for two residents (Resident #15 and #20) out of 23 sampled residents. ...
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Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) or contraindication for a GDR for two residents (Resident #15 and #20) out of 23 sampled residents. This failure had the potential to keep any resident on a psychoactive medication from receiving the lowest possible dosage of medication due to not monitoring if a medication is treating the target symptom. The facility's census was 115.
The facility did not provide a policy regarding GDRs.
1. Review of Resident #15's medical record showed:
- An admission date of 04/23/21;
- Diagnoses of paranoid schizophrenia (a type of schizophrenia characterized by persistent delusions and hallucinations, primarily involving themes of persecution, mistrust, and conspiracy), anxiety disorder (excessive and uncontrollable feelings of fear or worry that interfere with daily life), attention-deficit/hyperactivity disorder (ADHD - a chronic condition including attention difficulty, hyperactivity, and impulsiveness), major depressive disorder (MDD - persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and bipolar disorder (a mental illness that causes extreme shifts in mood, energy, activity, and concentration);
- An order for perphenazine 8 mg, three times a day, related to paranoid schizophrenia, dated 05/17/23;
- An order for risperidone 1 mg, two tablets twice a day, related to ADHD, dated 08/30/22;
- An order for sertraline 100 mg, two tablets once a day, related to MDD, dated 04/24/21;
- An order for clonazepam 1 mg, one tablet every morning and bedtime, related to anxiety disorder, dated 06/28/24;
- An order for carbamazepine 300 milligrams (mg), one capsule twice a day, related to bipolar disorder, dated 03/18/24;
- An order for hydroxyzine 50 mg, three times a day, related to anxiety disorder, dated 12/04/23;
- Behavior notes showed no behaviors documented since 09/24/24;
- No documentation of GDRs attempted;
- No documentation of contraindication of medication adjustments.
Review of the pharmacist's progress notes showed:
- On 11/18/24, medication regimen review (MRR) completed. Recommendations are documented in a separate, written report;
- On 10/22/24, medication regimen review completed. Recommendations are documented in a separate, written report.
Review of the Medication Regimen Review Prescriber Recommendation, dated 11/17/24, showed:
- The resident is receiving perphanazine 8 mg three times a day for schizoaffective disorder, risperidone 2 mg two times a day for schizoaffective disorder, sertraline 200 mg one time a day for MDD, clonazepam 1 mg twice daily for anxiety, carbamazepine 300 mg two times a day for mood stabilizer, and hydroxyzine 50 mg three times daily for anxiety;
- Please consider one of the following: Will attempt a GDR, GDR for other psychotropic medications ordered is contraindicated; A brief note including patient behaviors that support the continued use of this regimen and why a GDR would be likely to impair the resident's function, increase distressed behavior, or exacerbate an underlying medical or psychiatric disorder; patient is stable and has improved functioning with the current dosages of medications. Dosage reductions would be detrimental. The benefits of a reduction do not outweigh the risks and is clinically contraindicated;
- No response from the physician.
The facility did not provide the Medication Regimen Review Prescriber Recommendation from October or documentation that the physician had addressed it.
Observation on 12/01/24 at 5:41 P.M. showed Resident #15 very tearful and crying.
During an interview on 12/01/24 at 5:41 P.M., Resident #15 said he/she thinks other residents are against him/her and says everybody hates him/her and wants him/her to go back to the locked unit. By the end of the interview, the resident stopped crying and was happy.
2. Review of Resident #20's medical record showed:
- An admission date of 08/09/22;
- Diagnoses of MDD, bipolar disorder, paranoid schizophrenia, and insomnia (inability to sleep);
- An order for paliperidone 234 mg, inject 1.5 milliliters (ml) every 28 days, related to bipolar disorder, dated 10/01/24;
- An order for lithium 300 mg, one tablet three times a day, related to paranoid schizophrenia, dated 05/01/24;
- An order for venlafaxine 150 mg, one tablet once a day, related to MDD, dated 08/09/22;
- An order for oxcarbazepine 150 mg, one tablet every morning and at bedtime, related to bipolar disorder, dated 08/08/24;
- An order for trazodone 100 mg, one tablet at bedtime, related to insomnia, dated 05/14/24;
- Behavior notes showed no behaviors documented since 03/18/24;
- No documentation of GDRs attempted for venlafaxine and trazodone;
- No documentation of contraindication of medication adjustments.
Review of the pharmacist's progress notes showed:
- On 11/18/24, medication regimen review completed. Recommendations are documented in a separate, written report;
- On 09/19/24, medication regimen review completed. Recommendations are documented in a separate, written report.
Review of the Prescriber Recommendations Pending a Response from the 09/18/24 MRR and dated 11/18/24, showed:
- The resident is receiving paliperidone 234 mg every 28 days for bipolar disorder, lithium 300 mg three times a day (reduced 05/01/24), venlafaxine 150 mg once daily for depression, oxcarbazepine 150 mg twice daily for bipolar disorder (reduced 08/08/24), and trazodone 100 mg at bedtime for insomnia;
- Please consider one of the following: Will attempt a GDR, GDR for other psychotropic medications ordered is contraindicated; A brief note including patient behaviors that support the continued use of this regimen and why a GDR would be likely to impair the resident's function, increase distressed behavior, or exacerbate an underlying medical or psychiatric disorder; patient is stable and has improved functioning with the current dosages of medications. Dosage reductions would be detrimental. The benefits of a reduction do not outweigh the risks and is clinically contraindicated; current signs/symptoms are clinically significant enough to warrant the continuation of medication therapy as this is affecting their quality of life. Benefits of this medication regimen has shown clinical benefit with improvement of signs/symptoms that have been distressing to patient;
- No response from the physician.
The facility did not provide the Medication Regimen Review Prescriber Recommendation from September or documentation that the physician had addressed it.
Observation of Resident #20 on 12/01/24 at 4:44 P.M. showed the resident sat in bed watching TV.
During an interview on 12/06/24 at 11:30 A.M., the Assistant Director of Nursing (ADON) said she used to be in charge of Medication Regimen Reviews and Gradual Dose Reductions (GDRs), but the Director of Nursing (DON) who started in June took them over. Normally, she would get an email from the pharmacist with the recommendations and she would sort them out by medical doctor or psychiatric doctor. Then the doctor should write his/her response on the recommendation with what they want and sign them. She would do some by email and some she would have the doctors address when they do rounds.
During an interview on 12/06/24 at 11:51 A.M., the DON said she's in charge of MRRs and GDRs now. She will send them out, meaning email them out to the practitioners. They should respond sooner rather than later with their recommendations.
During an interview on 12/06/24 at 3:45 P.M., the Administrator, DON, and ADON said they would expect GDRs to be attempted on all psychotropics at least twice in two separate quarters the first year and annually after that.
During a telephone interview on 12/19/24 at 10:07 A.M., the consultant pharmacist said he/she will send the medication regimen reviews and a tracking sheet to the facility on a monthly basis. The Administrator, Medical Director, DON, regional nurse, and floor nurses all get a copy of it. He/She would expect there to be attempted GDRs at least twice in the first year and annually after that. The goal is to get a timely physician response on whether to attempt a GDR or a contraindication as to why there should be no GDR, but he/she has noticed there has been a hold up lately in getting those responses. He/She has spoken with the DON, so he/she is hopeful they will address the problem in the near future.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures. This deficient practice affected two residents (Resid...
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Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures. This deficient practice affected two residents (Resident #111 and #315) out of 23 sampled residents and three residents (Residents #61, #77, and #83) outside the sample and had the potential to affect all residents in the facility. The facility's census was 115.
The facility did not provide a food temperature policy.
Observation of the lunch meal on 12/03/24 at 1:15 P.M. showed:
- Macaroni salad with a temperature of 60 degrees Fahrenheit (F);
- Pears with a temperature of 55 degrees F;
- Deviled egg with a temperature of 51 degrees F;
- Tomato with a temperature of 58 degrees F.
Review of the steam table temperature logs for October and November showed:
- No logs provided for the month of October;
- Logs provided for November did not have dates listed, so the Dietary Manager (DM) listed November dates at the top of the logs.
During an interview on 12/01/24 at 4:56 P.M., Resident #83 said the food is getting better, but it's horrible and unappealing.
During an interview on 12/01/24 at 5:33 P.M., Resident #77 said sometimes food, like pasta, isn't hot like it should be.
During an interview on 12/02/24 at 9:48 A.M., Resident #61 said the food is up and down. We'll get one week of good food and two weeks of bad food.
During an interview on 12/02/24 at 9:53 A.M., Resident #315 said the food is not good.
During an interview on 12/03/24 at 12:54 P.M., Resident #111 said the food is not edible and he/she orders most of his/her meals out.
During an interview on 12/05/24 at 2:36 P.M., the DM said he/she would expect cold foods to have a temperature at 41 degrees or below when it is served to resident. He/She would expect all temperature logs to be completed per regulation.
During an interview on 12/06/24 at 3:45 P.M., the Administrator said she would expect cold food to be served at a temperature of 41 degrees or below with temperature logs completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during perineal (peri) care (cl...
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Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during perineal (peri) care (cleaning the genital and anal areas of the body) for two residents (Resident #4 and #66) outside the sample. The facility failed to implement enhanced barrier precautions (EBP) during perineal and wound care for one resident (Resident #6) out of 23 sampled residents and failed in the prevention of communicable disease in regard to tuberculosis (TB-a communicable disease that affects the lungs and is characterized by fever, cough and difficulty breathing) screening/testing of two residents (Resident # 8 and #23) out of five sampled residents. The facility's census was 115.
Review of the Centers for Medicare & Medicaid Services (CMS) memorandum QSO-24-08-NH, dated 03/20/24, showed:
- CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards;
- EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status;
- The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control;
- EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities;
- EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing;
- EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO;
- EBP should be used for any residents who meet the above criteria, wherever they reside in the facility;
- For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line (a thin flexible tube that is inserted into a large vein to provide medications, fluids, and blood) urinary catheter (a flexible tube inserted into the bladder to drain urine), feeding tube, tracheostomy/ventilator (surgical opening in the neck used to provide airway for breathing) and wound care (any skin opening requiring a dressing).
Review of the facility's Infection Control Policy, reviewed 10/24/24, showed:
- Standard/Universal Precautions used to prevent contact with blood or other potentially infectious material, and will be utilized by facility personnel;
- Hand hygiene refers to washing with soap or alcohol based hand rubs that do not require water;
- Hands shall be washed with soap and water when visibly soiled with dirt, body fluids, blood or after direct or indirect contact with such, and before eating and after using restroom;
- In absence of visible soiling of hands, alcohol based rubs are preferred for hand hygiene;
- Wash hands after removing gloves;
- Wear gloves when direct contact with blood, body fluids, mucus membranes, non-intact skin and other potentially infected material is anticipated;
- Change gloves as necessary, during care of a resident to prevent cross-contamination from one body site to another;
- Do not reuse gloves;
- Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, before going to another resident, and wash hands or use alcohol based rub immediately to avoid transfer of micro oganisms to other residents or environment;
- Do not wear gloves from one resident to another or walking down hallway;
- Wear a mask and eye protection or face shield to protect eyes, nose and mouth during procedures and resident care activities that are likely to generate splashes or sprays;
- Wear a gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions that may cause soiling;
- Remove soiled gown as promptly as possible and perform hand hygiene prior to leaving room;
- EBP not addressed in the Infection Control policy.
Review of the facility's Peri-Care policy, reviewed 08/24/24, showed:
- It is the practice of this facility to provide perineal care to all incontinent residents as needed and during routine bath time in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown;
- Peri-care will be completed when a resident is incontinent, soiled, during routine bath time, and as needed;
- The policy did not address hand hygiene or glove use during peri-care.
Review of the facility's Handwashing policy, undated, showed:
- Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures;
- When to wash hands: to prevent cross contamination when changing tasks or any time a contaminated surface is touched;
- Staff is educated on the importance of hand washing and retrained and reminded as necessary on the above guidelines;
- Handwashing per guidelines should occur between each task;
- Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines.
Review of the facility's document, Your Five Moments for Hand Hygiene, undated, showed:
- The World Health Organization (WHO) recommends that medical professionals should clean their hands before touching a patient, before clean procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings.
Review of the facility's TB Testing Policy, reviewed 08/25/24, showed:
- In order to minimize the risk of resident acquiring, transmitting, or experiencing complications from tuberculosis, the facility will screen residents upon admission and annually;
- Upon admission, each resident will have a two-step TB test administered and read per protocol;
- Annually, each resident will be screened for TB, and the Director of Nursing (DON) and physician will be notified of any questions answered affirmative.
1. Observation on 12/05/24 at 12:50 P.M. of Resident #6's peri and wound care showed:
- Certified Nursing Assistant (CNA) L and CNA M washed hands and gloved;
- CNA L and CNA M removed the resident's wet brief and CNA L cleaned the front peri area wearing only gloves;
- CNA M rolled resident to his/her left side, and held in place for CNA L to clean buttocks;
- CNA L, with the same soiled gloves, cleaned the resident's buttocks with a clean wipe;
- Licensed Practical Nurse (LPN) N washed hands, then cleaned wound on the resident's buttock and placed dressing, wearing only gloves;
- LPN N removed gloves and sanitized hands before leaving room;
- CNA L, CNA M, and LPN N did not wear a gown for the duration of peri care and wound care;
- Resident #6 did not have an EBP sign on his/her door or EBP supplies available outside or near his/her door.
During an interview on 12/05/24 at 2:35 P.M., LPN N said EBP should be used for wound precautions, to prevent spread of MRDOs. EBP should be worn when transferring and toileting residents with catheters, central lines, and tube feedings. Staff should wear gloves, gowns, and goggles/masks for wound care, depending on the wound. The facility has carts with the EBP supplies in different locations and EBP should have been worn during Resident #6's care.
During an interview on 12/05/24 at 2:54 P.M., CNA L said EBP would include gowns and gloves and are kept in the clean supply or med supply room. CNA L said he/she should have worn EBP during Resident #6's care.
During an interview on 12/05/24 at 2:54 P.M., CNA M said EBP would be worn if someone had something infectious, and the facility would let staff know. There was not anything in place like that for Resident #6 and, at that time, he/she was unaware of any resident in the facility placed on EBP.
2. Observation on 12/05/24 at 1:20 P.M. of Resident #4's peri care showed:
- CNA O donned gloves without performing hand hygiene and moved the resident's bedside table;
- CNA K brought in washcloths and a towel, put them on the sink, and donned gloves without performing hand hygiene;
- CNA K and CNA O transferred the resident from wheelchair to bed via mechanical lift;
- CNA K took the lift into the hall and attempted to spray it with an alcohol bottle zip tied to the lift, but said the bottle wasn't spraying very well, so he/she put the bottle back;
- CNA K removed gloves, washed hands, donned gloves, obtained trash liners from his/her pocket and handed them to CNA O;
- CNA O spread out two liners on the bed;
- CNA K and CNA O removed the resident's soaked brief and pulled it out from under the resident as they both rolled the resident. CNA K put the wet brief into the trash liner that CNA O held open;
- CNA K opened the nightstand drawer with the same soiled gloves and obtained a bottle of peri wash;
- CNA K turned on the faucet at the sink with the same soiled gloves, wet the washcloth with water, sprayed peri wash onto the washcloth, and set the washcloth and peri wash bottle on the nightstand;
- CNA K removed the lift pad from under the resident, put the lift pad and bed pad in the trash liner that CNA O held open;
- CNA K wiped the resident's front peri area with the same washcloth folding it over with each use, then used a dry towel on the resident's peri area without changing gloves or performing hand hygiene;
- CNA K and CNA O, with the same soiled gloves, rolled the resident side to side and both cleaned the resident's buttocks with a new washcloth sprayed with peri wash and dried with a new towel then disposed of washcloth and towel in trash liner on bed;
- CNA K opened the nightstand drawer to obtain barrier cream, removed gloves, washed hands for approximately three seconds, while CNA O touched gloves in glove dispenser hanging on the wall, still wearing the same soiled gloves;
- CNA O removed gloves, did not perform hand hygiene and, with bare hands, handed a new pair of gloves to CNA K to don;
- CNA O retrieved new gloves for himself/herself from the glove dispenser on the wall and donned gloves;
- CNA K applied barrier cream to the resident's buttocks, removed gloves, washed hands for approximately three seconds, and donned new gloves;
- CNA K picked up the soiled bags from the bed, set them on the floor, then covered the resident with a blanket;
- CNA K removed gloves, picked up trash bags from floor with bare hands, then set the bags back down on the floor, washed hands, and picked up the trash bags again;
- CNA O removed gloves, washed hands and exited room;
- CNA K put trash in soiled utility room and washed hands in the employee restroom by the nurses' station.
During an interview on 12/05/24 at 1:50 P.M., CNA K said he/she would wash hands before care, in between, and if the resident is both wet and had a bowel movement, he/she would wash hands and change gloves before cleaning up the bowel movement, then wash hands before leaving the room. He/She would sanitize when out of the resident's room after care. He/She would try to not touch other things in the room with dirty hands. CNA O said he/she agreed with what CNA K said.
3. Observation on 12/05/24 at 1:57 P.M. of peri care for Resident #66 showed:
- CNA K washed hands in the resident's room and donned gloves;
- CNA O obtained clean gloves, put them in his/her pocket, washed his/her hands, then took gloves from pocket and donned them;
- CNA K and CNA O transferred the resident from the wheelchair to the bed with a gait belt (a device used for assistance with transfers and walking);
- CNA K removed the resident's pants and soaked brief as CNA O laid trash liners on the bed;
- Without changing gloves or performing hand hygiene, CNA K laid a clean brief on the bed;
- CNA O picked up the clean brief and set it on the wheelchair with same gloves used to hold bags open for CNA K to place the resident's soiled clothing and brief;
- CNA K removed gloves, washed hands, sprayed washcloths with peri wash, handed a washcloth to CNA O, who wiped the resident's front peri area, folding the cloth with each wipe, and dried the resident with a clean towel;
- CNA O assisted the resident to roll and, with the same washcloth and wearing the same soiled gloves, wiped bowel movement six times, folding the washcloth over each time, then disposed of the washcloth in the trash liner CNA K held;
- Wearing the same soiled gloves and with a clean, dry towel, CNA O dried the resident's buttocks, picked up the clean brief from the resident's wheelchair, and put it on the resident while CNA K held the soiled bag;
- CNA K and CNA O removed gloves. CNA K washed hands while CNA O did not;
- The resident removed his/her socks, handed them to CNA O, who put the socks in the resident's wheelchair next to the bed. CNA O then covered the resident with a blanket;
- CNA O did not wash hands prior to leaving the room.
4. Review of Resident #8's medical record showed:
- admission date of 01/04/24;
- First-step TB test given on 01/04/24, read on 01/08/24, one day late, with results of 0 millimeters (mm);
- Second-step TB test given on 01/19/24, read on 01/22/24, results of 0 mm.
During an interview on 12/05/24 at 4:26 P.M., the DON said the results of Resident #8's first step had been read a day late.
5. Review of Resident #23's medical record showed:
- admission date of 05/27/22;
- A TB screening, dated 08/12/24, indicated further instructions needed due to resident had prolonged cough;
- No documentation of further instruction requested or orders for further testing.
During an interview on 12/05/24 at 4:21 P.M., the DON said she would expect at minimum for a resident that did not have a passing annual screening to at least have a chest X-ray, but this occurred before her time.
During an interview on 12/06/24 at 3:45 P.M., the Administrator and DON said they would expect staff to change gloves or sanitize their hands between dirty to clean and to change dirty gloves before touching items or the residents. They would expect staff to use EBP when a resident has wounds, tracheostomies (a surgical procedure that creates an opening in the windpipe and inserts a tube to provide an airway), peg tubes (a thin, flexible tube inserted through the skin of the abdomen directly into the stomach used for food, fluids, or medication), or communicable diseases. The EBP PPE is to be stored somewhere close to resident rooms or the nurse's station where staff can easily access it. They would expect TB tests to be read per regulation and residents with a positive TB screening to have the physician notified and a chest X-ray completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents in the facility. The facility's ce...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents in the facility. The facility's census was 115.
Review of the facility's policy, Pest Control, dated 08/24/24, showed:
- This facility will ensure the facility remains clean and free from pests;
- Daily cleaning of facility will be maintained;
- Monthly contracted pest control company will treat inside and outside of facility;
- Entry points to facility will be kept in good repair;
- Residents will be provided bags for their snacks they keep in their rooms.
Observation of the kitchen on 12/01/24 at 7:17 P.M. showed:
- Approximately two dozen live cockroaches in the oven that scattered when the oven door was opened;
- A live cockroach crawling up the wall near the coffee maker.
Observation of the kitchen on 12/03/24 at 11:50 P.M. showed:
- A live cockroach on a pair of oven mitts lying on a shelf next to the oven;
- Multiple live cockroaches inside the oven;
- A dead cockroach in the floor to the right of the oven.
Observation of the dry goods storage room on 12/03/24 at 11:53 A.M. showed a dead cockroach in front of the walk-in refrigerator.
Observation of the main dining room serving area on 12/03/24 at 12:12 P.M. showed:
- A dead cockroach smashed between the lid and top of the water reservoir area on the coffee maker the staff were using to serve residents coffee;
- Multiple mouse droppings throughout the serving counter cabinets and drawers;
- A dead insect in the steam table well.
Observation of the nursing office on locked portion of B hall on 12/05/2024 at 11:55 A.M. showed a small cockroach crawling on the floor out from under the desk.
During an interview on 12/05/24 at 2:36 P.M., the Dietary Manager (DM) said he/she would expect the kitchen to be free from pests. They have had an on going issue with cockroaches. He/She doesn't know who the pest control company is, but knows they typically spray once a month.
During an interview on 12/05/24 at 2:52 P.M., Dietary Aide C said cockroaches have been an ongoing issue. He/she knows someone comes to spray for them, but he/she guesses it has not been working.
During an interview on 12/05/24 at 2:59 P.M., Dietary Aide I said cockroaches have been an issue in the facility.
During an interview on 12/06/24 at 11:36 A.M., Dietary Aide G said he/she has seen cockroaches in the facility and they have been an ongoing issue. He/she knows the facility has someone that comes to spray for them, but he/she still sees them.
During an interview on 12/05/24 at 3:45 P.M., the Maintenance Director said there is a book for pest control for employees to note issues with pests, and the company will look at it when they get to the facility to spray each month. The facility recently started using a different pest control company, who comes once a month unless they call for extra services. He/she did not have the pest control book because the pest control company took it with them when they came last Tuesday. The company sprayed and put out tamper-proof traps on their last visit.
During an interview on 12/06/24 at 3:45 P.M., the Administrator said he/she would expect the facility to be free from pests.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These...
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Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 115.
Review of the facility's Handwashing policy, undated, showed:
- Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures;
- Wash hands and exposed portions of arms immediately before engaging in food preparation;
- When to wash hands: after handling garbage or garbage cans, dirty trays or dishes, or anything soiled; as often as necessary during food preparation to remove soil/contamination, and to prevent cross contamination when changing tasks; any time a contaminated surface is touched;
- Staff is educated on the importance of hand washing and retrained and reminded as necessary on the above guidelines;
- To ensure safe and proper food handling during food preparation and service, the food code states that food items should not be handled with bare hands;
- Handwashing per guidelines should occur between each task;
- Gloves should be worn if handling food is necessary. Extra caution should be taken when multiple tasks are being completed;
- Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines.
The facility did not provide a policy regarding food storage.
Observations on 12/01/24 at 7:15 P.M. of the kitchen showed:
- Dirt, debris, and trash throughout the floor;
- Pile of empty boxes near the kitchen door;
- Two large round trash cans with no lids on them;
- Black carbon buildup on stove top and oven;
- Black carbon and debris buildup inside the convection oven;
- Approximately two dozen live cockroaches inside the stove top oven;
- Two missing knobs on front of the stove top;
- Black carbon buildup on skillets, pots, pans, and cooking sheets;
- A small cockroach crawling up the wall near the coffee maker;
- Debris on countertops throughout the kitchen.
Observation on 12/01/24 at 7:20 P.M. of the dry goods storage area showed:
- A large dented can of solid packed apples on the can storage rack;
- Dirt and debris throughout the floor.
Observation on 12/01/24 at 7:22 P.M. of the refrigerator showed:
- A tray containing small sealed cups of salad dressing, undated and unlabeled;
- An unsealed bag of sandwiches.
Observation on 12/03/24 at 11:50 A.M. of the kitchen showed:
- Dietary Aide F in the kitchen without a hairnet;
- Dirt, debris, and trash throughout the floor;
- Debris on countertops throughout the kitchen;
- Black carbon buildup on stove top and oven;
- Black carbon and debris buildup inside the convection oven;
- Two missing knobs on front of the stove top;
- Black carbon buildup on skillets, pots, pans, and cooking sheets;
- A pair of stained, torn oven mitts sitting on the counter near the oven with a live cockroach crawling on them;
- An opened container of peanut butter with an expiration date of 11/27/24;
- Two opened containers of jelly in a squeeze bottle that said refrigerate after opening stored on the lower cabinet behind the stove top oven.
Observation on 12/03/24 at 11:52 A.M. of the dry goods storage area showed:
- Dirt and debris throughout the floor;
- Two dead cockroaches in the floor;
- A large dented can of chocolate flavored syrup in the can storage rack;
- Two five gallon containers of Sunburst Chemical sitting in the floor.
Observation on 12/03/24 at 12:12 P.M. of the lunch meal service showed:
- Dietary Aide H served trays to residents in the main dining room and did not sanitize in between serving residents;
- Dietary Aide I touched multiple dirty surfaces, including pans, serving station, scoops and plastic wrap and then touched clean plates, including the center of the plates and residents' food while wearing the same soiled gloves;
- Dietary Aide C touched multiple dirty surfaces including pans, serving station, scoops, plastic wrap, and a dirty trash can lid and then touched residents' food and the inside sections of divided plates while wearing the same soiled gloves;
- A dead cockroach smashed in the lid of the water reservoir on the coffee maker that staff were using to serve residents coffee;
- Dietary Aides F and G touched the ice scoop to the inside and rims of residents' personal cups, which residents had been using throughout the day;
- Dietary Aides F and G put the ice scoop into the ice bucket to store between refilling residents' cups;
- Dietary Aides F and G touched the drink pitchers to the rims of residents' personal cups, which residents had been using throughout the day when they were filling each resident's cup for the lunch meal;
- Dietary Aides F and G did not wear gloves or sanitize their hands during the entire lunch meal service.
During an interview on 12/05/24 at 2:36 P.M., the Dietary Manager (DM) said he/she would expect the kitchen to be free from pests. The facility has had an ongoing issue with cockroaches, but he/she knows there is a new company that is coming to spray for them. He/She doesn't know who the pest control company is, but knows they typically spray once a month. He/She would expect staff to wear hairnets in the kitchen and to sanitize their hands and change their gloves after touching something dirty and before touching food or assisting residents. He/She would expect all temperature logs to be completed per regulation. He/She would expect food requiring refrigeration to be stored in the refrigerator and all foods to be stored in appropriately-sealed containers or packages with dates and labels on them. He/She would expect the kitchen and equipment to be free from dirt, debris, and black carbon buildup. It is very challenging to get the buildup off the equipment. Dented cans are taken out of the can storage rack to be sent back to the food company. He/She would expect items past their best by date to be discarded and the dry goods storage area to be free from chemicals.
During an interview on 12/05/24 at 2:52 P.M., Dietary Aide C said he/she should change gloves or sanitize hands when touching anything that's not food and when touching surfaces. Cockroaches have been an issue and they spray, but he/she guessed it's not working.
During an interview on 12/05/24 at 2:59 P.M., Dietary Aide I said cockroaches have been an issue in the facility. He/She should change gloves between dirty to clean surfaces and he/she should wash his/her hands before putting on new gloves. He/She should wear a hairnet in the kitchen.
During an interview on 12/06/24 at 11:36 A.M., Dietary Aide G said he/she has seen cockroaches in the facility and they have been an ongoing issue. He/She knows the facility has someone that comes to spray for them, but he/she still sees them. He/She should sanitize his/her hands every time he/she touches something unsanitary. He/She will wear gloves, but do not change them every time and the facility does not train them to sanitize between the residents. He/She should wear a hairnet when in the kitchen. The ice scoop and pitchers should not touch the resident's cups when staff serve drinks.
During an interview on 12/05/24 at 3:45 P.M., the Maintenance Director said there is a book for pest control for employees to note issues with pests, and the company will look at it when they get to the facility to spray each month. The facility recently started using a different pest control company, who comes once a month unless they call for extra services. He/She did not have the pest control book because the pest control company took it with them when they came last Tuesday. The company sprayed and put out tamper-proof traps on their last visit.
During an interview on 12/06/24 at 3:45 P.M., the Administrator and Director of Nursing (DON) said they would expect the facility to be free from pests. They would expect staff to change gloves or sanitize their hands between dirty to clean, to change dirty gloves before touching items, the residents, or resident food. They would expect hairnets to be worn in the kitchen, the kitchen and equipment to clean and free from carbon buildup, dirt and debris, refrigerated items to be stored in the refrigerator, food to stored in appropriately-sealed containers and dated and labeled, items past the best by date to be discarded, and the dry goods storage area to be free from chemicals.
Sept 2023
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide personal funds and a final accounting of resident personal funds with the balance of those funds within thirty days of discharge fo...
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Based on interview and record review, the facility failed to provide personal funds and a final accounting of resident personal funds with the balance of those funds within thirty days of discharge for one resident (Resident #203) out of two closed records sampled in the resident fund review. The facility also failed to notify one sampled resident (Resident #15) out of 20 sampled residents and four residents (Resident #7, #13, #45, and #59) outside the sample and/or the responsible parties of the resident's fund balances remaining above $5,762.00 (the limit which should trigger a notification) for the months of August 2023 and September 2023. The facility census was 97.
Review of the facility's policy titled, Management/Protection of Residents Funds, revised 04/03/23, showed:
- The facility shall furnish the resident with a written receipt for all expenditures and deposits regarding any of the resident's funds deposited with the facility;
- A record of all transactions regarding the resident's funds shall be maintained by the facility in accordance with the generally accepted accounting principles;
- If the resident receives Medicaid (MCD) (a public health insurance program for people with low income) benefits, the facility shall notify the resident when the amount in his/her account has reached $200.00 less than the Social Security Income (SSI) (a program that provides cash payments to disabled children, disabled adults, and individuals aged 65 or older who are citizens or nationals of the United States) resource limit for one person and that if the amount in the account in addition to the value of the resident's other non-exempt resources reaches the SSI resource limit for one person, the resident may lose eligibility for MCD or SSI;
- The policy did not address a final accounting of resident personal funds within 30 days of discharge.
1. Review of Resident #203's closed medical record showed he/she was discharged to another facility on 11/04/22.
Review of the discharged resident's trust transaction history printed on 09/27/23 showed the following:
- On 08/01/23, the resident's remaining fund balance was $8,131.47;
- On 08/01/23, the resident's interest distribution was $1.09;
- On 08/31/23, the resident's remaining fund balance was $8,132.56.
During an interview on 09/27/23 at 11:21 A.M., the Business Office Manager (BOM) said he/she was not aware a resident should have a final accounting of personal funds and provide the balance of those funds within thirty days after discharge. He/she said there was a discharged resident that the corporate office had sent his/her remaining funds back to social security. The social security office sent the funds back to the facility. The BOM said corporate would be contacted and address the discharged resident's funds remaining in the trust.
During an interview on 09/27/2023 5:11 P.M., the Administrator said a resident should have a final accounting of personal funds and provide the balance of those funds within thirty days after discharge. The corporate office has been notified and the concern has been addressed.
2. Review of Resident #7's trust transaction history printed on 09/27/23 showed the following:
- On 08/03/23, the resident's fund balance was $22,221.60;
- On 08/17/23, the resident's fund balance was $24,650.21;
- On 09/01/23, the resident's fund balance was $24,196.72;
- On 09/21/23, the resident's fund balance was $23,567.36.
Review of the resident's record showed no evidence of letters or notifications to the resident and/or responsible party of the balance nearing the SSI resource limit.
3. Review of Resident #13's trust transaction history printed 09/27/23 showed the following:
- On 08/01/23, the resident's fund balance was $19,085.60;
- On 08/03/23, the resident's fund balance was $19,913.37;
- On 09/01/23, the resident's fund balance was $19,776.89;
- On 09/25/23, the resident's fund balance was $19,755.72.
Review of the resident's record showed no evidence of letters or notifications to the resident and/or responsible party of the balance nearing the SSI resource limit.
4. Review of Resident #15's trust transaction history printed 09/27/23 showed the following:
- On 08/01/23, the resident's fund balance was $12,963.53;
- On 08/15/23, the resident's fund balance was $19,761.53;
- On 09/01/23, the resident's fund balance was $20,190.71;
- On 09/21/23, the resident's fund balance was $18,332.71.
Review of the resident's record showed no evidence of letters or notifications to the resident and/or responsible party of the balance nearing the SSI resource limit.
5. Review of Resident #45's trust transaction history printed on 09/27/23 showed the following:
- On 08/01/23, the resident's fund balance was $8,179.02;
- On 08/03/23, the resident's fund balance was $9,737.02;
- On 09/01/23, the resident's fund balance was $9,512.92;
- On 09/05/23, the resident's fund balance was $8,229.76.
Review of the resident's record showed no evidence of letters or notifications to the resident and/or responsible party of the balance nearing the SSI resource limit.
6. Review of Resident #59's trust transaction history printed on 09/27/23 showed the following:
- On 08/03/23, the resident's fund balance was $6,675.38;
- On 09/05/23, the resident's fund balance was $7,805.25;
- On 09/18/23, the resident's fund balance was $7,441.25;
- On 09/25/23, the resident's fund balance was $6,126.94.
Review of the resident's record showed no evidence of letters or notifications to the resident and/or responsible party of the balance nearing the SSI resource limit.
During an interview on 09/27/23 at 11:21 A.M., the BOM said the social service designee (SSD) is notified from the corporate level of resident funds nearing the MCD amount allowed. The BOM was not sure if a letter had been sent notifying the resident and/or responsible party of his/her fund balance nearing or over the MCD limit.
During an interview on 09/27/2023 4:02 P.M., SSD A said corporate informs him/her when a resident needs to spend money to keep the balance below the MCD limit allowed. The responsible party is notified via phone conversation. The responsible party verbally gives permission to the facility to purchase items the resident needs and/or requests. SSD A had not been told to send a letter notifying the resident and/or responsible party of the amount nearing the MCD limit. He/she will start sending the required notification letters to meet the requirement.
During an interview on 09/27/2023 4:11 P.M., SSD B said corporate informs him/her when a resident needs to spend money to keep the balance below the MCD limit allowed. The responsible party is notified via phone conversation. The responsible party verbally gives permission to the facility to purchase items the resident needs and/or requests. SSD B has been in his/her position since July 2022 and had never been told to send a letter notifying the resident and/or responsible party of the amount nearing the MCD limit.
During an interview on 09/27/2023 5:11 P.M., the Administrator said the facility calls the responsible party when resident funds near the MCD limit. She was not aware that a letter needed to be sent notifying the resident and/or responsible party, but understood for documentation purposes. She said notification letters would be sent to the resident and/or responsible parties when resident funds near the MCD limit from now on.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0570
(Tag F0570)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of resident's personal funds) for at least one and one half times the average month...
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Based on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of resident's personal funds) for at least one and one half times the average monthly balance of the resident's personal funds for the last 12 consecutive months from September 2022 through August 2023. The facility census was 97.
Review of the facility's policy titled, Management/Protection of Residents Funds, revised 04/03/2019, showed the facility has a surety bond to assure the security of the resident's personal fund deposited with facility.
Review of the resident's personal funds account for the last 12 consecutive months from September 2022 through August 2023 showed:
- The facility's approved bond amount equaled $100,000.00;
- The average monthly balance of the resident's personal funds equaled $85,598.03;
- An average monthly balance of $85,598.03 rounded to the nearest thousand equaled $86,000.00, at one and one half times will equal the required bond amount of at least $129,000.00.
During an interview on 09/27/23 at 9:07 A.M., the Business Office Manager (BOM) said the surety bond should be one and one half times the amount on the ledger. An email was sent to the corporate office addressing the current surety bond amount. The BOM said the monthly resident trust fund amounts have increased due to increased census.
During an interview on 09/26/23 at 9:28 A.M., the Administrator said the surety bond amount should be one and one half times the amount of the resident trust balance to meet the regulatory requirement. The corporate office was notified and the concern has been addressed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required time frames ...
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Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required time frames for 13 residents (Resident #14, #15, #17, #18, #21, #29, #31, #34, #48, #54, #55, #68, and #89) out of 20 sampled residents. The facility's census was 97.
Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed:
- It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline;
- Resident assessments will be initiated in accordance with the automated data processing requirements. Within seven days after completion of a resident's assessment, the MDS Coordinator will encode the following information for each resident in the facility: admission Assessment, Annual Assessment, Significant change in status Assessment, Quarterly review Assessment, a subset of items upon a resident's transfer, reentry, discharge, and death;
- Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other assessments must be submitted within 14 days of the completion date.
Review of the Resident Assessment Instrument (RAI) Manual showed:
- For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600);
- The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment;
- For the admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later than 13 days after the Entry Date (A1600);
- For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300).
1. Review of Resident #14's medical record showed:
- An admission date of 08/06/21;
- A comprehensive annual MDS assessment with ARD of 08/18/22, CAA completion date of 09/06/22, and MDS completion date of 09/06/22;
- No CAAs completed within 14 days of the ARD.
2. Review of Resident #15's medical record showed:
- An admission date of 12/08/22;
- A comprehensive admission MDS assessment with CAA completion date of 01/09/23, and MDS completion date of 01/09/23;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
3. Review of Resident #17's medical record showed:
- An admission date of 06/11/18;
- A comprehensive annual MDS assessment with ARD of 08/10/21, CAA completion date of 12/27/21, and MDS completion date of 12/27/21;
- A comprehensive annual MDS assessment with ARD of 08/24/22, CAA completion date of 02/08/23, and MDS completion date of 02/08/23;
- No CAAs completed within 14 days of the ARD;
- No comprehensive MDS assessment within 366 days of the last comprehensive MDS assessment.
4. Review of Resident #18's medical record showed:
- An admission date of 03/25/22;
- A comprehensive admission MDS assessment with CAA completion date of 04/12/22, and MDS completion date of 04/12/22;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
5. Review of Resident #21's medical record showed:
- An admission date of 08/09/22;
- A comprehensive admission MDS assessment with CAA completion date of 08/29/22, and MDS completion date of 08/29/22;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
6. Review of Resident #29's medical record showed:
- An admission date of 09/01/22;
- A comprehensive admission MDS assessment with CAA completion date of 01/05/23, and MDS completion date of 12/05/22;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
7. Review of Resident #31's medical record showed:
- An admission date of 03/16/18;
- A comprehensive annual MDS assessment with ARD of 02/09/22, CAA completion date of 05/13/22, and MDS completion date of 05/13/22;
- No CAAs completed within 14 days of the ARD;
- A comprehensive annual MDS assessment with ARD of 02/10/23, CAA completion date of 03/17/23, and MDS completion date of 03/17/23;
- No CAAs completed within 14 days of the ARD.
8. Review of Resident #34's medical record showed:
- An admission date of 04/24/23;
- A comprehensive admission MDS assessment with CAA completion date of 06/09/23, and MDS completion date of 06/09/23;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
9. Review of Resident #48's medical record showed:
- An admission date of 04/27/22;
- A comprehensive admission MDS assessment with CAA completion date of 05/13/22, and MDS completion date of 05/13/22;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
10. Review of Resident #54's medical record showed:
- An admission date of 03/31/23;
- A comprehensive admission MDS assessment with CAA completion date of 04/25/23, and MDS completion date of 04/25/23;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
11. Review of Resident #55's medical record showed:
- An admission date of 07/26/23;
- A comprehensive admission MDS assessment with CAA completion date of 08/09/23, and MDS completion date of 08/09/23;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
12. Review of Resident #68's medical record showed:
- An admission date of 09/09/22;
- A comprehensive admission MDS assessment with CAA completion date of 01/20/23, and MDS completion date of 01/20/23;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
13. Review of Resident #89's medical record showed:
- An admission date of 11/09/22;
- A comprehensive admission MDS assessment with CAA completion date of 02/07/23, and MDS completion date of 02/07/23;
- No CAAs completed within 14 days of admission;
- No comprehensive admission MDS assessment within 14 days of admission.
During an interview on 10/03/23 at 11:00 A.M., the MDS Coordinator said she is unsure if the facility has a policy regarding MDS, but she completes the MDS tracking records and assessments per the RAI Manual. She would expect them to be completed and transmitted in a timely manner.
During an interview on 10/03/23 at 11:04 A.M., the Administrator said she would expect the MDS tracking records and assessments to be completed and transmitted in a timely manner per policy and the RAI Manual.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required timeframe for te...
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Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required timeframe for ten residents (Resident #14, #17, #18, #21, #29, #31, #34, #35, #47, and #55) out of 20 sampled residents. The facility's census was 97.
Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed:
- It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline;
- Resident assessments will be initiated in accordance with the automated data processing requirements. Within seven days after completion of a resident's assessment, the MDS Coordinator will encode the following information for each resident in the facility: admission Assessment, Annual Assessment, Significant change in status Assessment, Quarterly review Assessment, a subset of items upon a resident's transfer, reentry, discharge, and death;
- Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other assessments must be submitted within 14 days of the completion date.
Review of the Resident Assessment Instrument (RAI) Manual showed:
- The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of previous OBRA assessment (Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment) + 92 calendar days);
- The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type.
1. Review of Resident #14's medical record showed:
- An admission date of 08/06/21;
- A comprehensive annual MDS assessment with a completion date of 09/06/22;
- A quarterly MDS assessment with a completion date of 03/20/23;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
2. Review of Resident #17's medical record showed:
- An admission date of 06/11/18;
- A quarterly MDS assessment with a completion date of 03/04/22;
- A quarterly MDS assessment with a completion date of 06/08/22;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
3. Review of Resident #18's medical record showed:
- An admission date of 03/25/22;
- A quarterly MDS assessment with a completion date of 10/27/22;
- A quarterly MDS assessment with a completion date of 03/06/23;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
4. Review of Resident #21's medical record showed:
- An admission date of 08/09/22;
- A comprehensive admission MDS assessment with a completion date of 08/09/22;
- A quarterly MDS assessment with a completion date of 03/24/23;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
5. Review of Resident #29's medical record showed:
- An admission date of 09/01/22;
- A comprehensive admission MDS assessment with a completion date of 12/05/22;
- A quarterly MDS assessment with a completion date of 05/09/23;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
6. Review of Resident #31's medical record showed:
- An admission date of 02/11/20;
- A quarterly MDS assessment with a completion date of 08/19/22;
- A quarterly MDS assessment with a completion date of 04/19/23;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
7. Review of Resident #34's medical record showed:
- An admission date of 04/22/19;
- A comprehensive significant change MDS assessment with a completion date of 01/04/22;
- A quarterly MDS assessment with a completion date of 05/17/22;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
8. Review of Resident #35's medical record showed:
- An admission date of 03/30/22;
- A quarterly MDS assessment with a completion date of 07/22/22;
- A quarterly MDS assessment with a completion date of 03/05/23;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
9. Review of Resident #47's medical record showed:
- An admission date of 03/24/21;
- A comprehensive annual MDS assessment with a completion date of 04/13/22;
- A quarterly MDS assessment with a completion date of 07/19/22;
- A quarterly MDS assessment with a completion date of 10/27/22;
- A quarterly MDS assessment with a completion date of 3/6/23;
- The facility failed to complete a quarterly MDS assessment within 92 days of each prior MDS assessment.
10. Review of Resident #55's medical record showed:
- An admission date of 04/27/22;
- A quarterly MDS assessment with a completion date of 08/29/22;
- A quarterly MDS assessment with a completion date of 01/04/23;
- The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment.
During an interview on 10/03/23 at 11:00 A.M., the MDS Coordinator said she is unsure if the facility has a policy regarding MDS, but she completes the MDS tracking records and assessments per the RAI Manual. She would expect them to be completed and transmitted in a timely manner.
During an interview on 10/03/23 at 11:04 A.M., the Administrator said she would expect the MDS tracking records and assessments to be completed and transmitted in a timely manner per policy and the RAI Manual.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to electronically transmit Minimum Data Set assessments (MDS, a federally mandated assessment completed by the facility) in a timely manner an...
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Based on interview and record review, the facility failed to electronically transmit Minimum Data Set assessments (MDS, a federally mandated assessment completed by the facility) in a timely manner and in accordance with guidelines for nine residents (Resident #14, #18, #31, #34, #35, #47, #54, #55, and #89) of 20 sampled residents. The facility census was 97.
Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed:
- It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline;
- Resident assessments will be initiated in accordance with the automated data processing requirements. Within seven days after completion of a resident's assessment, the MDS Coordinator will encode the following information for each resident in the facility: admission Assessment, Annual Assessment, Significant change in status Assessment, Quarterly review Assessment, a subset of items upon a resident's transfer, reentry, discharge, and death;
- Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other assessments must be submitted within 14 days of the completion date.
Review of the Resident Assessment Instrument (RAI) Manual for assessment transmission showed the following:
- Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date (V0200C2+14 days);
- Entry tracking records must be transmitted electronically no later than the entry date + 14 days;
- All other MDS assessments must be submitted within 14 days of the MDS completion date (Z0500B+14 days).
1. Review of Resident #14's medical record showed:
- A discharge return anticipated MDS assessment, dated 03/09/22 and completed 03/15/22;
- The discharge return anticipated MDS assessment transmitted and accepted 05/02/22;
- The facility failed to ensure the discharge return anticipated MDS assessment was transmitted electronically within 14 days of the completion date;
- An entry MDS tracking record, dated 03/11/22 and completed 03/15/22;
- The entry MDS tracking record transmitted and accepted 05/02/22;
- The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date;
- A comprehensive annual MDS assessment, dated 08/18/22 and completed 09/06/22;
- Care plan decisions for the comprehensive annual MDS assessment completed 09/06/22;
- The comprehensive annual MDS assessment transmitted and accepted 10/06/22;
- The facility failed to ensure the comprehensive annual MDS assessment was transmitted electronically within 14 days of the care plan completion date;
- A comprehensive annual MDS assessment, dated 08/11/23 and completed 08/18/23;
- Care plan decisions for the comprehensive annual MDS assessment completed 08/18/23;
- The comprehensive annual MDS assessment transmitted and accepted 09/08/23;
- The facility failed to ensure the comprehensive annual MDS assessment was transmitted electronically within 14 days of the care plan completion date.
2. Review of Resident #18's medical record showed:
- A comprehensive admission MDS assessment, dated 04/06/22 and completed 04/12/22;
- Care plan decisions for the comprehensive admission MDS assessment completed 04/12/22;
- The comprehensive significant change in status MDS assessment transmitted and accepted 05/02/22;
- The facility failed to ensure the comprehensive admission MDS assessment was transmitted electronically within 14 days of the care plan completion date.
3. Review of Resident #31's medical record showed:
- An entry MDS tracking record, dated 06/29/22 and completed 07/03/22;
- The entry MDS tracking record transmitted and accepted 07/15/22;
- The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date;
- A discharge return anticipated MDS assessment, dated 09/30/22 and completed 10/12/22;
- The discharge return anticipated MDS assessment transmitted and accepted 10/27/22;
- The facility failed to ensure the discharge return anticipated MDS assessment was transmitted electronically within 14 days of the completion date;
- An entry MDS tracking record, dated 10/04/22 and completed 10/11/22;
- The entry MDS tracking record transmitted and accepted 10/27/22;
- The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date;
- A discharge return anticipated MDS assessment, dated 11/01/22 and completed 11/07/22;
- The discharge return anticipated MDS assessment transmitted and accepted 11/22/22;
- The facility failed to ensure the discharge return anticipated MDS assessment was transmitted electronically within 14 days of the completion date.
4. Review of Resident #34's medical record showed:
- A quarterly MDS assessment, dated 09/01/22 and completed 09/16/22;
- The quarterly MDS assessment transmitted and accepted 10/06/22;
- The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the completion date.
5. Review of Resident #35's medical record showed:
- An entry MDS tracking record, dated 03/30/22 and completed 03/31/22;
- The entry MDS tracking record transmitted and accepted 05/02/22;
- The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date.
6. Review of Resident #47's medical record showed:
- A quarterly MDS assessment, dated 01/06/22 and completed 03/09/22;
- The quarterly MDS assessment transmitted and accepted 05/02/22;
- The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the completion date;
- A discharge return anticipated MDS assessment, dated 03/09/22 and completed 03/17/22;
- The discharge return anticipated MDS assessment transmitted and accepted 05/02/22;
- The facility failed to ensure the discharge return anticipated MDS assessment was transmitted electronically within 14 days of the completion date;
- A comprehensive annual MDS assessment, dated 04/05/22 and completed 04/13/22;
- Care plan decisions for the comprehensive annual MDS assessment completed 04/13/22;
- The comprehensive annual MDS assessment transmitted and accepted 05/02/22;
- The facility failed to ensure the comprehensive annual MDS assessment was transmitted electronically within 14 days of the care plan completion date.
7. Review of Resident #54's medical record showed:
- An entry MDS tracking record, dated 03/31/23 and completed 04/13/23;
- The entry MDS tracking record transmitted and accepted 04/18/23;
- The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date.
8. Review of Resident #55's medical record showed:
- An entry MDS tracking record, dated 10/04/22 and completed 01/04/23;
- The entry MDS tracking record transmitted and accepted 01/09/23;
- The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date;
- An entry MDS tracking record, dated 12/20/22 and completed 01/04/23;
- The entry MDS tracking record transmitted and accepted 01/09/23;
- The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date.
9. Review of Resident #89's medical record showed:
- A quarterly MDS assessment, dated 08/10/23 and completed 08/18/23;
- The quarterly MDS assessment transmitted and accepted 09/08/23;
- The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the completion date.
During an interview on 10/03/23 at 11:00 A.M., the MDS Coordinator said she is unsure if the facility has a policy regarding MDS, but she completes the MDS tracking records and assessments per the RAI Manual. She would expect them to be completed and transmitted in a timely manner.
During an interview on 10/03/23 at 11:04 A.M., the Administrator said she would expect the MDS tracking records and assessments to be completed and transmitted in a timely manner per policy and the RAI Manual.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident #47) out of 20...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident #47) out of 20 sampled residents. The facility's census was 97.
Review of the facility's policy titled, Physician/Medication Order Policy, last reviewed 12/2018, showed:
- For written transfer orders, implement if signed and dated by the resident's current attending physician;
- If not signed by the current attending physician, the receiving nurse should verify the order with the current attending physician.
Review of Resident #47's medical record showed:
- Latest admission date of 09/08/2023;
- Diagnoses of impairment of speech following a stroke, hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), dementia (the loss of cognitive thinking, remembering, and reasoning that interferes with a person's daily life and activities), anemia (lack of blood), Wernicke's encephalopathy (a type of brain injury), gastro-esophageal reflux disease (digestive disease with heartburn and acid reflux), schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior), and tobacco use;
- admission to the hospital on [DATE] through 09/08/23;
- No order for lab work or lab results since last admission;
- discharged to the hospital on [DATE].
Review of the resident's hospital Discharge summary, dated [DATE], showed:
- An admission date of 08/31/23 and discharge date of 09/08/23;
- Active hospital problems/diagnosis of hypokalemia (low potassium in the blood), thrombocytopenia (deficiency of platelets in the blood, this causes bleeding into the tissues, bruising, and slow blood clotting after injury), pancytopenia (abnormally low amounts of red blood cells, white blood cells, and platelets), and abnormal coagulation profile (condition in which the blood's ability to form clots is outside of the normal range);
- An order for a Complete Blood Count and a Comprehensive Metabolic Profile (blood work to monitor condition) in one week.
During an interview on 09/28/23 at 09:45 A.M., Registered Nurse (RN) G said when a resident is admitted to the facility from the hospital, he/she would contact the attending physician to verify orders and make a note regarding this upon admission.
During a telephone interview on 09/28/23 at 04:36 P.M., the resident's attending physician said he/she expects the nursing staff to follow the hospital discharge orders.
During an interview on 09/28/23 at 7:25 P.M., the Director of Nursing (DON) said when a resident comes back from the hospital with new orders, the new orders are faxed to the primary care physician (PCP) for review. Orders are reviewed by the PCP, then medications are ordered from pharmacy and appointments are scheduled. A note should be put in that the orders were sent to the PCP and what orders were verified.
During an interview on 09/28/23 at 7:25 P.M., the Director of Operations (DOP) said orders should be put in the system after a resident returns from the hospital once the orders are verified by the PCP. If the PCP does not continue a hospital order, a note should be put in the record to show the order was addressed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain an order for a Foley catheter (a flexible tube...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain an order for a Foley catheter (a flexible tube inserted into the bladder to drain urine), catheter care, and provide a diagnosis for the use of a catheter for one resident (Resident #47) out of 20 sampled residents The facility census was 97.
Review of the facility's policy titled, Catheter Care Protocol, updated on 02/2021, showed:
- Skin care guidelines should be followed once a day and more often as needed.
Review of Resident #47's medical record showed:
- An admission date of 03/24/21;
- admitted to the hospital on [DATE] and returned to the facility on [DATE] with a Foley catheter;
- No diagnosis for a Foley catheter;
- The September 2023 Physician's Order Sheet, (POS) showed no order for the Foley catheter or for catheter care;
- The facility failed to obtain a diagnosis, an order for the catheter placement, and for catheter care.
Observation of the resident on 09/26/23 at 10:15 A.M. showed the resident with an indwelling catheter.
Review of the resident's hospital update, dated 09/27/23, showed the resident was admitted on [DATE] with a diagnosis of a Urinary Tract Infection.
During an interview on 09/28/23 at 09:45 A.M., Registered Nurse (RN) G said residents with a Foley catheter need orders for the catheter itself, catheter care, to empty the catheter once per shift, and to change the catheter once a month if approved by the physician.
During an interview on 09/28/23 at 7:25 P.M., the Administrator and Director of Operations said they would expect a resident to have an order for a catheter, as well as an order for catheter care to be provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #14) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of 20 sampled residents. The facility's census was 97.
The facility did not provide a policy.
Review of Resident #14's electronic medical record (EMR) showed:
- admitted on [DATE];
- Diagnoses of PTSD, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (MDD, a long-term loss of pleasure or interest in life), and generalized anxiety disorder (GAD, severe, ongoing anxiety that interferes with daily activities);
- An order for the resident to see the dentist, psychiatry, and podiatrist as needed, dated 08/06/21;
- Consent for Psychiatric Services, signed by resident, dated 09/13/21;
- Psychosocial visit notes from the psychiatric nurse practitioner, dated 10/06/22, 02/01/23, 03/09/23, 04/13/23, 05/17/23, and 08/08/23;
- A psychosocial progress note stating the resident attended and actively participated in a group activity, completed by social services and dated 04/06/23;
- No Abuse/Neglect or PTSD Assessment completed.
Review of the resident's Physician's Order Sheet (POS), dated September 2023, showed:
- An order for quetiapine (antipsychotic medication) 200 milligrams (mg) by mouth daily for schizophrenia, dated 06/23/22;
- An order for hydroxyzine (antianxiety medication) 25 mg three times daily for anxiety, dated 10/12/22;
- An order for hydroxyzine 50 mg three times daily for severe anxiety, dated 10/26/22;
- An order for Effexor (antidepressant medication) 300 mg daily for major depressive disorder, dated 10/26/22;
- An order for trazodone (antidepressant medication) 100 mg at bedtime for insomnia, dated 03/09/23.
Review of the resident's comprehensive care plan, initiated 09/21/21, showed:
- Problem: Resident is currently on psychotropic medications (any drug that affects behavior, mood, thoughts, or perception) related to schizophrenia and PTSD;
- Interventions: Administer psychotropic medications as ordered by physician; consult with pharmacy and medical doctor (MD) to consider dosage reduction when clinically appropriate at least quarterly; monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia (condition affecting the nervous system, often caused by long-term use of some psychiatric drugs), extrapyramidal side effects (EPS, commonly referred to as drug-induced movement disorders such as shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person;
- Goal: I will remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension (low blood pressure), gait disturbance, constipation or cognitive/behavioral impairment through review date;
- Problem: Based on the resident's Level 2 PASRR (a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) the resident has a diagnosis of Schizophrenia, GAD, PTSD, mild episode of MDD without psychotic features, and primary insomnia;
- Interventions: Resident will follow up with physician as needed and will take medication as ordered.
- Goal: Resident will not have any issues with diagnoses through next review;
- Problem: Resident has a diagnosis of schizophrenia, anxiety, PTSD, and major depressive disorder, and is currently on antidepressants and antipsychotics (medications that relieve symptoms of psychosis, such as delusions (false beliefs) and hallucinations (seeing or hearing something that is not there) which puts the resident at risk for adverse reactions and falls;
Interventions: Staff will follow their protocol should I fall or have an adverse reaction to medications;
- Goal: I will not have adverse reactions or falls through my next review;
- No interventions or goals to maintain the resident's psychosocial and mental health;
- No documentation showing the resident had past trauma, physical or verbal abuse, substance or alcohol abuse or any triggers that would cause the resident trauma;
- No interventions for how the facility would address these behaviors if they occurred or how the facility would provide support to the resident.
During an interview on 09/27/23 at 08:55 A.M., Resident #14 said staff has never assessed or asked about PTSD or triggers. They don't do that here. No outside staff, such as a nurse practitioner, has asked about him/her about PTSD. Resident would not say if he/she had any triggers or what they were.
During an interview on 09/28/23 at 12:37 P.M., Social Services Designee (SSD) B said there is an Abuse/Neglect assessment that contains information about PTSD and they fill it out on all new admits. He/She has been trained to de-escalate if a resident happens to have a trigger.
During an interview on 09/28/23 at 07:45 P.M., the Administrator said he/she would expect residents to be screened for PTSD and the care plan to include appropriate interventions related to the resident's PTSD concerns. The Administrator said this should be screened for upon admission, quarterly, and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility census was 97.
Review...
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Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility census was 97.
Review of the facility's policy titled, Storage and Labeling of Medications, updated 2/13/23, showed:
- Medications and biologicals are stored safely, securely and properly, following the manufacturer's recommendations or those of the supplier;
- The facility receives medications dispensed by the provider pharmacy in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medication from one container to another or return partially used medication to the original container;
- All medications dispensed by the pharmacy are stored in the container with the pharmacy label;
- Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy;
- Drugs dispensed in the manufacturer's original container will be labeled with manufacturer's expiration date;
- Certain medications or package types, such as, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency;
- When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated;
- The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating;
- The nurse will check the expiration date of each medication before administering it;
- No expired medication will be administered to a resident;
- All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining.
Review of the manufacturer's package for Tuberculin Purified Protein Derivative (a sterile aqueous solution used in the testing for tuberculosis) solution, undated, showed:
- Discard opened product after 30 days.
Observation on 9/27/23 at 09:28 A.M. of the medication room on Wing A showed:
- Two opened vials of Tuberculin solution not labeled with the date opened.
Observation on 9/27/23 at 10:30 A.M. of the medication room on Wing B showed:
- Two opened vials of Tuberculin solution not labeled with the date opened.
Observation on 9/27/23 at 02:30 P.M. of the medication cart for Wing A showed:
- One clear prescription bottle with a hand written label Vit D3 50,000 containing approximately 20 white capsules without an original manufacturer or pharmacy label or an expiration date.
During an interview on 09/27/23 at 10:45 A.M., Licensed Practical Nurse (LPN) F said he/she would label Tuberculin solution vials with the date opened and discard 30 days after being opened.
During an interview on 09/28/23 at 09:45 A.M., Registered Nurse (RN) G said he/she would follow the manufacturer's instructions on the box or insert to know when to discard an opened vial.
During an interview on 09/28/23 at 06:24 P.M., LPN F said medications should stay in the original bottles and should not be transferred to a different unlabeled bottle.
During an interview on 09/28/23 at 06:31 P.M., the Director of Nursing (DON) said she would expect medications to remain in the original dispensed bottle or packaging, and Tuberculin solution should be labeled with the opened date and discarded 30 days after being opened.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the residents' environment was free of accident hazards by not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the residents' environment was free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in occupied resident room sinks and a community shower, which put residents at increased risk for burns caused by scalding water. This practice affected five residents (Resident #15, #47, #56 #67, and #77) out of 20 sampled residents and seven residents (Resident #1, #26, #9, #53, #65, #75, and #90) outside the sample. This practice could have potentially affected all residents. The facility census was 97.
Review of the Burn Foundation website showed hot water causes third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters:
- In 1 second at 156 degrees F;
- In 2 seconds at 149 degrees F;
- In 5 seconds at 140 degrees F;
- In 15 seconds at 133 degrees F.
Review of the facility policy regarding water temperatures, updated 11/2022, showed:
- Facility will maintain appropriate water temperatures in resident care areas;
- Staff will be educated on safe water temperatures upon employment and on a regular basis;
- Thermometers will be available as needed for use by all staff;
- Staff will report abnormal findings, such as complaints of water too cold or too hot, burns or redness, or any problems with water temperatures to the supervisor and/or maintenance staff;
- Water temperatures will be set to a temperature of no more than the state's allowable maximum water temperature;
- Maintenance staff will check water heater temperature controls and temperatures of tap water in all hot water circuits weekly and as needed;
- Water temperature logs will be kept in a binder for review and compliance.
Observation on 09/28/23 at 10:45 A.M. showed Registered Nurse (RN) G said Ohhh, that's hot as he/she was washing his/her hands between changing gloves while in room [ROOM NUMBER].
Observations of water temperatures on 9/28/23 from 12:27 P.M. through 4:42 P.M. taken with two digital thermometers showed:
- room [ROOM NUMBER] water temperature recorded 132.8° (degrees Fahrenheit) at the sink;
- room [ROOM NUMBER] water temperature recorded 133.8° at the sink;
- room [ROOM NUMBER] water temperature recorded 128° at the sink;
- room [ROOM NUMBER] water temperature recorded 130° at the sink;
- room [ROOM NUMBER] water temperature recorded 128° at the sink;
- room [ROOM NUMBER] water temperature recorded 132° at the sink;
- All the rooms tested were occupied and sinks were for resident use;
- The A hall shower room to the right of the nurse's station water temperature recorded 125.8°;
- Kitchen handwashing sink water temperature recorded at 133.8°.
During an interview on 9/28/23 at 3:15 P.M., the Maintenance Assistant said water temperatures are to be checked weekly, but he/she has only been there a couple of weeks and has not checked the temperatures. Maintenance Assistant said he/she was not aware of a log where water temperatures are recorded.
During an interview on 09/28/23 at 3:18 P.M., the Maintenance Supervisor (MS) said that water temps are checked weekly. The MS said he/she had only been there a short time and the previous water temperature logs were not able to be found. He/she said the temperatures are not checked and recorded weekly, as he/she does not have a thermometer. The MS said the temperatures were reported to be too hot about a month ago and a company came out and inspected the water heaters and adjusted the temperatures, but were unable to determine what water heater goes to what hall.
Observation on 09/28/23 at 3:20 P.M. showed the water heaters labeled #3 and #4 currently had a temperature setting of 130° and the two remaining unlabeled water heaters had a temperature setting of 140°. The MS adjusted all four water heaters to 120° in order to bring down the water temperatures.
During an interview on 09/28/23 at 3:25 P.M., the Administrator said he/she was unable to locate the water temperature logs from the previous maintenance supervisor. The Administrator said maintenance should be checking water temperatures weekly to monitor. The Administrator was unaware of how long it had been since the water temperatures were checked and unaware current maintenance did not have a thermometer. The Administrator immediately inserviced the Maintenance Supervisor and Maintenance Assistant on checking water temperatures weekly and started a log, as well as provided maintenance with a thermometer.
During an interview on 09/28/23 03:50 P.M., Certified Medication Technician (CMT) L said he/she had noticed that water was too hot in rooms throughout the building, but had not reported it.
During an interview on 09/28/23 at 3:51 P.M., the Dietary Manager said he/she had reported the temperatures being too hot about a month or so ago and maintenance fixed the issue. DM then ran her hand under the water in the handwashing sink in the kitchen and reported the water was too hot again.
Observation on 09/28/23 at 3:53 P.M. showed Dietary Aide K washed hands in the handwashing sink in the kitchen. Dietary Aide K said the water was too hot and has been hot. He/she did not report the water was too hot.
During an interview on 09/28/23 at 4:45 P.M., the Administrator said maintenance was currently draining the water heaters to bring down the water temperatures and all staff and residents have been made aware not to use their sinks or the shower room until the water temperatures are back within range.
Interviews with Resident #1, #9, #15, #26, #53, #56, #65, #67, #75, #77 and #90 showed they did think their water got a little hot, but none had ever been burned or injured from using their sink or the shower room. None of the residents had mentioned the hot water to any staff.
During an interview on 9/28/23 at 5:55 P.M., the Administrator said the water temperatures were remaining consistent after being monitored and draining the water heaters. The facility will continue water temperature monitoring and address any temperatures above 120 immediately.
Observations on 09/28/23 from 6:00 P.M. through 6:35 P.M. showed:
- room [ROOM NUMBER] water temperature recorded 118.5° at the sink;
- room [ROOM NUMBER] water temperature recorded 118° at the sink;
- room [ROOM NUMBER] water temperature recorded 113.5° at the sink;
- room [ROOM NUMBER] water temperature recorded 117.6° at the sink;
- room [ROOM NUMBER] water temperature recorded 117.3° at the sink;
- room [ROOM NUMBER] water temperature recorded 118.2° at the sink;
- The A hall shower room to the right of the nurse's station water temperature recorded 115.5°;
- Kitchen handwashing sink water temperature recorded at 117.1°.
During an interview on 09/28/23 at 7:25 P.M., the Director of Operations (DOP) said he/she would expect the facility to be monitoring water temperatures as per policy and for temperatures out of range to be reported immediately by staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kit...
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Based on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 97.
The facility did not provide a policy.
Review of the facility's current employee list, dated 09/24/23, showed a hire date of 09/16/22 for the Dietary Manager (DM).
During an interview on 09/26/23 at 10:59 A.M., the Administrator said she did not know the DM had been in her position for almost a year. She was aware the DM was not certified. The employee will be enrolled in an online course to start the certification process to meet the dietary manager requirement.
During an interview on 09/27/23 at 11:19 A.M., the DM said he/she was not aware of the requirement to become a Certified Dietary Manager (CDM) until the Administrator informed him/her of it a couple of days ago. The Administrator enrolled him/her for an online course to start the process of becoming a CDM.
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
Based on observation, interview, and record review, the facility failed to implement an infection control program and a risk management process specific to Legionella disease (a serious type of pneumo...
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Based on observation, interview, and record review, the facility failed to implement an infection control program and a risk management process specific to Legionella disease (a serious type of pneumonia caused by Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility also failed to maintain proper infection control practices for glucose monitoring for one resident (Resident #15) out of 20 sampled residents and five residents (Resident #5, #7, #34, #38, and #65) outside of the sample, and failed to perform hand hygiene during medication administration for one resident (Resident #15) out of 20 sampled residents and two residents (Resident #34 and #65) outside the sample. The facility census was 97.
1. The facility failed to provide a policy regarding Legionella.
During an interview on 09/28/23 at 3:15 P.M., the Maintenance Assistant said he/she was not aware if any routine checks for Legionella were being performed, as he/she just started a couple of weeks ago.
During an interview on 09/28/23 at 3:25 P.M., the Maintenance Supervisor (MS) said he/she did not know of any documentation related to waterborne pathogens or Legionella disease, nor were routine checks being performed. The MS said he/she has not worked at the facility for long and is still trying to find logs from the old maintenance man.
During an interview on 09/28/23 at 7:25 P.M., the Administrator said he/she would expect the Maintenance Supervisor to be performing checks for Legionella per the facility policy. The Administrator said checks were not being performed currently.
2. Review of the facility's Infection Control Policy, revised 02/22, showed:
- Hands shall be washed with soap and water whenever visibly soiled with dirt, blood or body fluids, or after direct or indirect contact with such;
- In absence of visible soiling of hands, alcohol-based hand rubs are preferred for hand hygiene;
- Wash hands after removing gloves;
- Ensure reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed.
Review of the facility's policy on glucometer (a machine used to measure blood sugars) disinfection protocol, dated 4/22/21, showed:
- Wash hands before applying gloves to check blood sugar;
- Wash hands after disinfecting device and discarding gloves;
- Cleanse glucometer with the disinfectant wipe, ensuring properly saturated;
- Leave wipe in contact with glucometer for the length of time designated by manufacturer recommendation.
- Allow device to dry for a minimum of 5 minutes or per manufacturer recommendation.
Review of the Micro-kill disinfecting wipes manufacturer's recommendations showed:
- Keep thoroughly wet for 3 minutes and allow to air dry;
- Use as many wipes as needed for the surface to remain wet for the entire contact time.
Observations on 09/27/23 showed:
- At 11:20 A.M., Certified Medication Technician (CMT) O performed blood sugar monitoring for Resident #7. CMT O failed to perform hand hygiene before applying gloves to use glucometer. CMT O cleaned the glucometer with a Micro-Kill wipe for 10 seconds, then discarded the wipe and placed the glucometer on top of the treatment cart. CMT O failed to perform hand hygiene;
- At 11:23 A.M., CMT O performed blood sugar monitoring for Resident #38. CMT O failed to perform hand hygiene before applying gloves to use glucometer. CMT O cleaned the glucometer with a Micro-Kill wipe for 10 seconds, then discarded the wipe and placed the glucometer on top of the treatment cart. CMT O failed to perform hand hygiene;
- At 11:26 A.M., CMT O performed blood sugar monitoring for Resident #5. CMT O failed to perform hand hygiene before applying gloves to use glucometer. CMT O cleaned the glucometer with a Micro-Kill wipe for 10 seconds, then discarded the wipe and placed the glucometer on top of the treatment cart. CMT O failed to perform hand hygiene;
- At 11:32 A.M., CMT O performed blood sugar monitoring for Resident #34. CMT O failed to perform hand hygiene before applying gloves to use glucometer. CMT O cleaned the glucometer with a Micro-Kill wipe for 10 seconds, then discarded the wipe and placed the glucometer on top of the treatment cart. CMT O failed to perform hand hygiene before or after medication administration;
- At 11:35 A.M., CMT O performed blood sugar monitoring for Resident #65. CMT O failed to perform hand hygiene before applying gloves to use glucometer. CMT O cleaned the glucometer with a Micro-Kill wipe for 10 seconds, then discarded the wipe and placed the glucometer on top of the treatment cart. CMT O failed to perform hand hygiene before or after medication administration;
- At 11:40 A.M., CMT O performed blood sugar monitoring for Resident #15. CMT O failed to perform hand hygiene before applying gloves to use glucometer. CMT O cleaned the glucometer with a Micro-Kill wipe for 10 seconds, then discarded the wipe and placed the glucometer on top of the treatment cart. CMT O failed to perform hand hygiene before or after medication administration.
During an interview on 09/27/23 at 01:45 P.M., CMT O said he/she would wash hands between residents and when visibly soiled. CMT O said he/she would wipe the glucometer off and let set for five minutes before using it again.
During an interview on 09/28/23 at 7:25 P.M., the Director of Nursing (DON) said he/she would expect hand hygiene to be performed between each resident while medications are administered or blood sugars are being checked. The DON said he/she would expect for the manufacturer guidelines to be followed when cleaning the glucometer between residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This affected ten residents (Resident #15, #22, #31, #43, #52, #55, #73, #86, #87, and #89) out of 20 sampled residents, five residents (Resident #28, #58, #71, #88, and #303), outside the sample, and had the potential to affect all residents. The facility's census was 97.
Review of the facility's Pest Control Policy, last revised March 2022, showed:
- The facility will remain clean and free from pests;
- Daily cleaning of facility will be maintained;
- Monthly contracted pest control company will treat inside and outside of facility;
- Entry points will be kept in good repair;
- Residents will be provided bags for snacks they keep in rooms.
1. Observation of Resident #15 showed:
- On 09/27/23 at 3:05 P.M., the resident sat in a wheelchair and a fly was observed on the right leg, then onto left leg. The fly buzzed around again and landed on his/her right hand;
- On 09/28/23 at 10:55 A.M., a fly was observed on the resident's left sock, buzzed around and landed on his/her hand, then on the abdomen, then landed on his/her leg during wound care of feet.
During an interview on 09/27/23 at 3:05 P.M., the resident said flies drive me crazy!
2. Observation of Resident #22's room on 09/25/23 at 3:36 P.M. showed:
- Three flies on a blanket;
- Six flies on the bed linen while he/she laid on the bed;
- Two flies on the windowsill;
- Several flies buzzed throughout the interview.
3. Observation of Resident #31 on 09/25/23 at 02:32 P.M. showed two flies buzzing the resident and crawling on the blanket.
4. Observation of Resident #43's room on 09/25/23 at 2:30 P.M. showed:
- Several flies on his/her over-the-bed table and nightstand;
- Two flies on the windowsill;
- He/she swatted at flies with a fly swatter throughout the interview.
5. Observation of Resident #52's room on 09/26/23 at 8:36 A.M. showed:
- Several flies on the bed linen while he/she laid on the bed;
- Several flies buzzed throughout the room.
During an interview on 09/26/23 at 8:36 A.M., Resident #52 said the flies were coming in when the staff open the door to let residents in and out to smoke.
5. Observation of Resident #55 on 09/26/23 at 11:20 A.M. showed four flies buzzing and crawling on the bed while the resident sat on the bed during the interview.
6. Observation of Resident #58 on 09/28/23 at 02:26 P.M. showed three flies buzzing the resident as he/she lay in bed with eyes closed.
7. Observation of Resident #73 on 09/26/23 at 11:52 A.M. showed:
- Several flies buzzed around the resident while he/she sat in a wheelchair in front of the exit door on B Hall;
- Two flies on his/her face.
8. Observation of Resident #87's room on 09/25/23 at 2:18 P.M. showed:
- Several flies on the bed and comforter while he/she laid on the bed;
- Several flies buzzed throughout the room.
During an interview on 09/25/23 at 2:18 P.M., Resident #87 said the flies have been a problem and reported more than once to staff. The flies come into the facility through the smoke door that leads outside. There is a fan that blows air over the door, but it doesn't help with the flies.
9. Observation on 09/25/23 at 8:34 A.M. and 09/26/23 at 3:39 P.M. of B Hall showed:
- Sunlight coming through a gap approximately two inches wide at the bottom and narrowing up to the top of the door leading to the outside designated smoke area;
- Several flies buzzed throughout the hall and around the smoke door.
10. Observation of Resident #88 on 09/25/23 at 11:50 A.M. showed two flies buzzing his/her face as he/she lay in bed.
During an interview on 09/25/23 at 11:50 A.M., the resident said the flies are so bad here.
10. Observation of Resident #89's room on 09/25/23 at 3:34 P.M. showed:
- Five flies on the pillow and bed linen while he/she laid on the bed;
- Two flies on the privacy curtain next to the bed;
- A fly on his/her face;
- He/she swatted at flies with both hands.
During an interview on 09/25/23 at 3:34 P.M., Resident #89 said the flies are bad in his/her room and he/she would like for someone to address the problem.
11. Observations of Resident #303 showed:
- On 09/25/23 at 11:48 A.M., a fly buzzing around and crawling on the bed while the resident sat in the bed;
- On 09/27/23 at 08:51 A.M., the resident lay in bed with his/her eyes closed and mouth open with two flies buzzing his/her face.
During an interview on 09/25/23 at 11:48 A.M., the resident said the flies are bad.
12. Observation on 09/26/23 at 4:09 P.M. of B Hall showed:
- Two flies on the staff and visitor bathroom located near the nurse's station;
- Three flies on the kiosk (wall-mounted computer) monitor screen between rooms [ROOM NUMBERS];
- Several flies on four chairs in front of the glass pane windows with a view of the outside designated smoke area;
- Several flies buzzed around the door leading to the outside designated smoke area;
- Several flies buzzed throughout the hall, resident rooms, and nurse's station;
- No fly control devices on B Hall.
13. Observation on 09/27/2023 at 8:56 A.M. of B Hall showed:
- Several flies buzzed around the door leading to the outside designated smoke area;
- Several flies buzzed throughout the hall, resident rooms, and nurse's station;
- No fly control devices on B Hall.
14. Observation of room [ROOM NUMBER] on 09/27/23 at 08:57 A.M. showed:
- The toilet with lid and seat up;
- Fecal matter splattered on toilet rim and on the bottom of the seat;
- Fly crawling on the bottom of the seat.
15. During an interview on 09/25/23 at 11:51 A.M., Resident #28 said the flies are bad.
16. During an interview on 09/25/23 at 2:47 P.M., Resident #86 said the flies are bad and come in from the smoke door when residents go and smoke outside. Staff is aware.
During Resident Council interviews on 09/27/23 at 9:20 A.M., the group collectively said that the flies are terrible and even though the facility sprays for bugs, they would like fly strips.
During an interview on 09/27/2023 at 9:38 A.M., Housekeeper C said he/she had seen flies on the halls, but did not report it. Flies had been a problem on B Hall and other staff have reported it. Housekeeper C said he/she does make sure rooms are cleaned, but it doesn't stop the flies from coming in. Maintenance is notified of any pest control issues.
During an interview on 09/27/23 at 09:58 A.M., Resident #71 said there was a big problem with flies and gnats.
During an interview on 09/27/2023 at 10:11 A.M., Certified Nursing Assistant (CNA) D said flies are a problem and continued to be a problem on B Hall. If there is a pest control problem, the maintenance department is notified. The facility is aware of the fly issue.
During an interview on 09/27/2023 at 10:13 A.M., CNA E said flies are a problem and have been a problem on B Hall. He/she said it had been reported to housekeeping and the facility is aware of the fly concern.
During an interview on 09/27/2023 at 10:16 A.M., Licensed Practical Nurse (LPN) F said the flies had been an issue on B Hall and in resident rooms for some time. The concern had been reported to the maintenance department and the facility is aware of the fly issue.
During an interview on 09/28/23 at 10:18 AM, the Maintenance Assistant said the facility switched pest control companies. We put up the blue things but had a resident that did not like them and removed from outlet and destroyed them. That resident is no longer here, so we can try them again.
During an interview on 09/28/23 at 7:25 P.M., the Administrator and Director of Operations said they would expect pest control practices to be appropriate. The facility installed fans at smoke doors and new plug in blue lights to help with the flies. Facility has recently switched pest control companies and they will be coming on a monthly basis. Administrator said a pest control binder will be started to ensure pest control issues are reported and addressed.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when Certified Nurses Assistant (CNA) A blocked the ...
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Based on observation, interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when Certified Nurses Assistant (CNA) A blocked the resident from entering the dining room and the resident responded by throwing a mug full of water on the CNA. The CNA retaliated by grabbing the mug forecefully from the resident's hand the handle broke. CNA A then threw her own water on the resident. The facility census was 98.
The Administration was notified on 07/19/23 of the Past Non-Compliance citation on 07/08/23. At the time of the event on 07/08/23 facility staff took appropriate corrective actions as confirmed by survey staff during the onsite visit. The deficiency was corrected on 07/08/23.
Record review of the facility Abuse, Neglect, Exploitation policy, undated, showed:
- Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family,members, legal guardians, friends or other individuals.
- Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including caretaker, of goods and or services that are necessary to attain or maintain, physical, mental and psychosocial well-being;
- Verbal Abuse means the use of oral. written or gestured languages that willfully includes derogatory and disparaging terms towards a resident or their families, or within their hearing regardless of their age, ability to understand, or disability;
- The facility will train staff on appropriate interventions to deal with aggressive and /or catastrophic reactions by residents;
- Observe resident behavior and their reaction to other residents, roommates and or tablemates. Place residents in accommodations and environments that keep them calm;
- Provide instruction to staff on care needs of residents. Supervise staff to identify inappropriate behaviors such as using derogatory language, rough handling;
- Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, utilize facility's abuse/neglect assessment and develop care needs according to findings.
Exhibit B
1. Record review of the facility's Incident Investigation, dated 07/08/23, showed:
- The Administrator (ADM) was informed CNA A threw water on and pushed Resident #1;
- CNA A was immediately removed from resident care area;
- Staff witnessed CNA A sitting in the hall, using a wheelchair as a seat. As Resident #1 ambulated down the hall towards the dining room with a coffee cup in her hand, CNA A rolled in the wheelchair to block the resident. CNA A told Resident #1 not to go in the dining room until he/she changed out of his/her soiled clothing;
- Resident #1 tried to go around CNA A, but CNA A kept moving to block him/her;
- Resident #1 threw a cup full of coffee on CNA A;
- CNA A grabbed Resident #1's hand, twisted the plastic cup and caused the handle to break;
- CNA A cussed the resident, grabbed her own cup of water and threw it on Resident #1;
- At that point the other staff on duty interceded and removed CNA A from the area.
Exhibit A
Review of Resident #1's medical record showed:
- An admission date of 11/11/22;
- Diagnoses included Diabetes, Hypertension, Alzheimer's Disease, Unspecified Psychosis;
- The Level 1 Nursing Facility Pre-admission Screening for Mental Illness, Mental Retardation or Related Condition (PASRR), dated 08/26/21, showed the resident exhibited confusion and required supervision and assistance with hygiene, dressing and toileting;
- A Nursing Progress Note, dated 07/8/23 at 9:45 A.M., said resident unable to recall details of altercation with CNA other than there were sprinkles on shirt. No injury noted to resident.
Exhibit D
Review of the quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument required to be completed by the facility staff), dated 06/20/23, showed:
- A score of six on the Brief Interview for Mental Status (a score of 0 to 7 suggests a resident is severely cognitively impaired);
- Resident #1exhibited delirium, inattention, disorganized thinking, delusions and verbal behaviors;
- The resident required supervision, cueing and oversight with his/her care.
Resident #1's Care Plan, last updated 01/04/23, showed:
- The resident becomes verbally aggressive when he/she does not like what others say or do;
- The resident will refuse to compromise with staff or residents in any manner;
- Interventions included the resident learning how to compromise and taking guidance from staff to minimize behaviors.
Exhibit D
Observation, on 07/19/23 at 12:50 P.M., showed Resident # 1 sitting at dining room table calm, smiling, nodding head yes to all questions. He/she was clean and without lingering odors.
During an interview, on 07/19/23 at 12:55 P.M., CNA B said:
- He/She had behavior deescalation training;
- On 07/8/23, after breakfast, he/she was at nurse's station on the memory unit and CNA A was sitting in a spare wheelchair (WC) outside of the nurse's station rolling back and forth in the hall;
- Resident #1 came up hall towards the dining room;
- CNA A rolled the WC in front of the resident, blocking entrance to the dining room;
- CNA A told the resident to go to his/her room and change out of his/her wet stinky clothes;
- The resident tried to go around CNA A, who continued to block the resident by rolling in the WC in front of him/her and said again but more loudly for the resident to go change his/her clothes;
- Resident #1 tried to kick CNA A and threw coffee on her;
- Then CNA A got up and threw his/her own cup of water on the resident, grabbed resident's hand and twisted coffee cup until the handle broke;
- Certified Medication Technician (CMT) A then came up the hall and separated the CNA A and the resident then reported to the charge nurse;
- Resident #1 is confused and has Alzheimer's. He/she informed CNA A to assist resident and talk to him/her calmly. CNA A was completely out of line.
During a telephone interview on 07/25/3 at 9:30 A.M., CMT A said:
- He/she had Behavior Deescalation training;
- On 07/8/23 at 9:30 A.M., he/she witnessed CNA A yell you stink and have piss all over you to Resident #1;
- As he/she headed up the hall to intervene, Resident #1 spit on CNA A, shouted leave me alone and then threw coffee on CNA A;
- CNA A grabbed the cup in Resident #1's hand and twisted until it broke;
-CNA A, cussed and threw his/her own cup of water on Resident #1;
- He/she separated them, taking Resident #1 to the dining room to sit and sending CNA A to the office and reported to the charge nurse.
Exhibit C
During telephone interview on 07/26/23 at 11:30 A.M., CNA A said:
- He/she has been working for the facility full time since 06/28/23;
- He/she had received abuse and neglect training and signed form;
- On 07/08/23 at 9:30 A.M., he/she was sitting in a spare WC at nurse's station on the Memory Care Unit, when Resident # 1 approached him/her;
- The resident smelled of pee and poop and he/she asked Resident #1 to go and change clothes;
- Resident #1 said no to changing clothes and tried to go around the WC;
- He/She rolled in front of the resident and would not let him/her go through;
- Resident #1 kicked out and threw coffee on his/her (CNA A's) head;
- The coffee was not hot enough to cause injury;
- CMT A took resident #1 to dining room and he/she left the unit to see the charge nurse;
- He/She was upset Resident had come at her and told charge nurse she wanted police called to charge the resident;
- He/she did not throw water on the resident, but was trying to rinse the coffee out of his/her hair;
- He/she then left the facility.
During an interview on 07/19/23 at 3:45 P.M., the ADM said:
- All staff receive Abuse and Neglect Training as well as Behavioral de-escalation inservices;
- He/she conducted the investigation and CNA A was verbally and physically abusive to Resident #1;
- CNA A will not be returning to work at this facility.
Complaint #'s MO00221142 AND MO00221187
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to provide a safe, sanitary and comfortable environment for the residents by not maintaining the B hall showers in a clean, mold-free manner. Th...
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Based on observation and interview, the facility failed to provide a safe, sanitary and comfortable environment for the residents by not maintaining the B hall showers in a clean, mold-free manner. The deficient practice has the potential to affect all 37 of the B hall residents. The facility census was 103
Observation on 07/06/23 at 1:30 P.M. of the first shower on B hall showed:
- Black mold-like build up starting at the top of the base tile going up the walls on all three sides of the shower stall;
- A thick, black build up along the tile where it meets the wall on all sides;
- The paint cracked and peeled exposing a previous layer of green paint;
- Large areas of missing paint exposing the dry wall underneath;
- The exposed dry wall had a black brown build up in the seams and around the shower apparatus;
- The grout between the tiles was black and there shower floor was dirty;
- The toilet in the shower room had spots of a dry, flaky brown substance;
- The wall on either side of the toilet was cracked with peeling paint.
Observation on 07/06/23 at 1:40 P.M. of the second shower on B hall showed:
-Black mold-like build up starting at the top of the base tile going up the walls on all three sides of the shower stall;
- The paint on the shower walls was cracked and peeling, exposing the dry wall underneath;
- The metal flashing of the corners were exposed on the shower stall;
- A large area of tile missing directly under the shower head;
- A chair with rusted metal legs sat in the middle of the shower;
- The shower floor was brown and dirty.
During an interview on 07/06/23, the Housekeeping Supervisor, (HS), said he/she is aware of the mold and has been attempting to remove in at least weekly for several months. The HS said scrubbing the mold did not work as it just comes back. The HS said he/she would not want to shower in these stalls.
During an interview on 07/06/23 at 1:40 P.M., the Maintenance Supervisor (MS) said he/she was aware of the deterioration of the shower stalls on B hall. The MS said the facility was planning on remodeling the B hall when the C hall developed issues that required immediate attention and B hall remodeling stopped. He/she said this has been an on-going problem for several months. The MS said there is currently not a date planned to complete the remodeling of B hall but did believe that the showers should be fixed.
During an interview on 07/06/23 at 2:00 P.M., the Administrator (ADM) said she was not aware of the conditions of the B hall showers. She said she would expect them to be in good repair for the B hall residents. The Adm said all 37 residents of the B hall use either the first or second shower.
During a phone call on 7/10/2023, the ADM said there is no policy that pertains to maintenance of the facility showers.
Complaint #MO220561
Mar 2023
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision when one cognitively impa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision when one cognitively impaired resident (Resident #1), who resided on a locked unit, gained access to an unlocked bathing room and was later found unresponsive, submerged in water in the bathtub by staff approximately 45 minutes after the last time staff noted his/her whereabouts. The resident had no signs of life after being removed from the water. Staff did not assist Resident #1 with bathing as directed on the care plan. Thirty three residents reside on the locked unit and the facility total census was 93.
The administrator was notified on [DATE] at 4:35 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification.
Record review of the Criteria for the Secured Unit dated [DATE] showed:
- Residents on the unit will have one or more of the following; mental illness, confusion, elopement risk, danger to self or others, behaviors, combative with staff or others, suicidal ideations, anxiety and requires less stimulation, requires a closer supervision regarding safety.
Record review of the facility's Showers/Bathing Policy, dated [DATE], showed:
- Showers/Baths will be offered at a frequency of at least two times per week, unless otherwise requested;
- If a resident has a specific preference related to bathing/showering this will be identified and staff will assist as needed;
- Staff will assist with bathing/showering as needed to ensure residents remain clean and odor free;
- Residents who are independent with bathing/showering will be monitored for compliance;
- Residents that resist bathing/showering will be added to their comprehensive care plan;
- The policy did not address how resident preferences will be made known to staff;
- The policy did not address how resident abilities will be made known to staff;
- The policy did not address the process for assessing a resident's ability to shower/bathe;
- The policy did not address how independent residents will be monitored for compliance or frequency.
Record review of the facility's investigation dated [DATE] showed:
- On [DATE], the Administrator (ADM) was notified Resident #1 had been found unresponsive in a bathtub full of water on B hall;
- The staff immediately called 911;
- CPR (cardiopulmonary resuscitation - an emergency life-saving procedure) was not initiated due to the resident being a do not resuscitate (DNR);
- Staff interviews showed the resident was last seen at approximately 4:00 P.M.;
- At approximately 4:45 P.M. the staff could not locate the resident and started a search;
- The resident was found in the shower room in the bathtub, the water was running and the resident was fully submerged, naked and unresponsive.
Observation on [DATE] at 12:45 P.M. of the B Hall, showed the bathroom door unlocked. The bathroom contained a commode, a shower stall and a bathtub approximately 60 inches long, 30 inches wide and 14 inches high.
1. Record review of Resident #1's Level 1 Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care, which consists of two potential levels of assessment), dated [DATE], showed:
- Met the federal definition of serious mental illness, but did not require specialized services;
- Diagnoses of Major Depressive Disorder (a mental disease characterized by low mood, low self-esteem and loss of interest), Personality Disorder (a mental disorder of rigid thinking and unhealthy thoughts); Major Neurocognitive Disorder (a new term for dementia); Generalized Anxiety Disorder; and long history of suicidal thoughts;
- Qualified for a Level 2 screening (more in depth assessment of the PASRR).
Review of Resident #1's Level 2 PASRR screening, dated [DATE], showed:
- Assessed needs included maximum assistance with activities of daily living (ADLs), especially bathing;
- Referral notes included poor judgment and poor insight;
- The resident required physical assist of staff for bathing.
Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated [DATE], showed:
- admission to the facility on [DATE];
- Severe cognition impairment;
- A need for physical assistance with bathing/showering;
- Diagnoses of anxiety, depression, Parkinson's Disease (a chronic degenerative disorder of the central nervous system), and Traumatic Brain Injury (TBI - a brain injury caused by an outside force).
Review of Resident #1's care plan, last revised on [DATE], showed:
- An increased risk for falls;
- An ADL self-care performance deficit related to Parkinson's diagnosis. Staff will assist with bathing, shaving, dressing and incontinent care as needed;
- Impaired cognitive function and thought process.
During an interview on [DATE] at 1:30 P.M., Certified Medication Technician (CMT) A said on [DATE], just before 5:00 PM, he/she was on A hall. Staff from B hall yelled for help and he/she responded. When CMT A entered the shower room on B hall, he/she saw Resident #1 naked and submerged in water in the bathtub with the water still warm and running. Certified Nurse Aide (CNA) F came into the room and attempted to hold Resident #1's head above the water until they could determine the code status.
CNA B said he/she is usually assigned to work the B hall secured unit. CNA B said most of the residents on the unit are mobile and able to come and go to the shower room as they please, to use the bathroom or to take a shower. CNA B said he/she observed Resident #1 working out earlier in the afternoon and noted nothing out of the ordinary with his/her behaviors. CNA B said he/she did not know Resident #1 had gone into the shower room. When the resident was discovered, CNA B did not go into the shower room, but stayed on the hall.
During an interview on [DATE] at 1:45 P.M., CMT C said the resident had been exercising on [DATE] at 1:30 P.M. He/she was not aware the resident was in the shower room until staffed yelled for help.
During an interview on [DATE] at 10:45 A.M., CNA E said he/she had seen the resident at 4:00 P.M. with no shirt on. CNA E said shortly after seeing Resident #1, he/she took residents outside to smoke. When CNA E came back in the building, Licensed Practical Nurse (LPN) D asked him/her to assist in locating Resident #1. After searching the hall and the rooms, he/she looked in the shower room and saw the resident in the tub. The water was still running and the resident was fully submerged, naked and on his/her side. CNA E said he/she was unaware if the resident required supervision with bathing.
During an interview on [DATE] at 6:00 P.M., LPN D said he/she was alerted to the shower room by CNA E. LPN D said after entering the shower room, he/she observed the resident laying in the bathtub, naked and submerged in water on his/her side, knees bent. LPN D said he/she was not aware the resident had entered the shower room unattended. The LPN had worked with the resident often and had no idea he/she was cognitively impaired. The LPN said in his/her opinion the resident did not appear cognitively impaired and was not aware of the diagnoses in the MDS and care plan. LPN D said the resident normally showered not bathed, but could not say how he/she confirmed the resident took a shower. LPN D said he/she has never looked at a resident's PASRR. LPN D said he/she and the other charge nurses get most of their historical information on residents from the discharge paperwork in the admission packet.
During an interview on [DATE] at 2:45 P.M., the resident's physician (PHY) said he/she had not been made aware of the resident's passing. The PHY said the resident required supervision and should never have been allowed to shower or bathe alone.
During an interview at 12:30 P.M., the ADM said the bathroom on the secured hall is always unlocked. They do not want to lock the shower door as residents use the toilet frequently and would be constantly asking staff for a key. The residents on B hall are residents with behaviors, but are physically able to shower without supervision based on the resident's physical ability. The ADM did not know what specific assessment was completed to determine physical ability or the criteria that would make a resident independent to shower/bathe unsupervised. The ADM said the resident was physically able to shower alone based on what she knew of him/her. The ADM said the residents who are deemed physically capable of showering are allowed to do so independently with no supervision. A shower list is kept and the staff try to document when the resident has showered. The ADM said none of the staff were aware or had ever seen evidence of a resident taking a tub bath. A resident could have entered the shower room without the staff knowing. The ADM said staff were unaware the resident wanted to use the bathtub instead of the shower. The ADM said on [DATE], the staff were not aware the resident had gone into the shower room. The ADM said since Resident #1 was able to shower unsupervised staff cannot say if he/she had taken a tub bath previously. The ADM said the staff do keep shower sheets when the residents shower, but could not explain the process as to how staff find out if a resident had showered. The ADM said she did not know what the resident's PASRR said, he/she had never looked at it. The ADM said the PASRR information should be part of the care plan.
During a telephone interview on [DATE] at 1:30 P.M., the detective said the preliminary autopsy results indicated Resident #1 drowned.
MO216036, 216266
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to incorporate relevant information and recommendations from the Pre-admission Screening and Resident Review (PASRR- a federal requirement to ...
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Based on record review and interview, the facility failed to incorporate relevant information and recommendations from the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care, which consists of two potential levels of assessment), to the comprehensive care plan for one resident (Resident #1) of four sampled residents. The facility census was 93.
1. Record review of Resident #1's Level 1 Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care, which consists of two potential levels of assessment), dated 4/30/2021, showed:
- Met the federal definition of serious mental illness, but did not require specialized services;
- Diagnoses of Major Depressive Disorder (a mental disease characterized by low mood, low self-esteem and loss of interest), Personality Disorder (a mental disorder of rigid thinking and unhealthy thoughts); Major Neurocognitive Disorder (a new term for dementia); Generalized Anxiety Disorder; and long history of suicidal thoughts;
- Qualified for a Level 2 screening (more in depth assessment of the PASRR).
Review of Resident #1's Level 2 PASRR screening, dated 5/11/2021, showed:
- Assessed needs included maximum assistance with activities of daily living (ADLs), especially bathing;
- Referral notes included poor judgment and poor insight;
- The resident required physical assist of staff for bathing.
Record review of Resident #1's care plan, last revised on 3/21/2023, showed:
- An increased risk for falls;
- An ADL self-care performance deficit related to Parkinson's diagnosis. Staff will assist with bathing, shaving, dressing and incontinent care as needed;
- Impaired cognitive function and thought process.
The resident's care plan did not address the resident's history of suicidal ideations, or physical assist with bathing.
During an interview on 3/27/2023 at 1:15 P.M., CNA B said he/she is usually assigned to work the B hall secured unit. CNA B said most of the residents on the unit are mobile and able to come and go to the shower room as they please, to use the bathroom or to take a shower. CNA B did not know Resident #1's care plan indicated he/she required assistance with bathing.
During an interview on 3/27/2023 at 2:45 P.M., the resident's physician said the resident required supervision and should never have been allowed to shower or bathe alone.
During an interview on 3/27/2023 at 6:00 P.M., Licensed Practical Nurse (LPN) D said he/she worked with the resident often and had no idea Resident #1 was cognitively impaired. The LPN was not aware of the diagnoses in the MDS and care plan or that Resident #1 was care planned for assistance with bathing. LPN D said the resident bathed unsupervised and unassisted.
During an interview on 3/28/2023 at 11:00 A.M., the Social Services Director (SSD) said he/she and the MDS Coordinator look over the PASSR and create a care plan. The SSD said he/she does not know how the resident's issues were missed.
During an interview on 3/27/2023 at 12:30 P.M., the Administrator said the PASRR information should be part of the care plan.
MO216036, 216266
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to develop and implement a comprehensive plan of care for one (Resident #1) of four sampled residents. The facility census was 93.
Record revi...
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Based on record review and interview, the facility failed to develop and implement a comprehensive plan of care for one (Resident #1) of four sampled residents. The facility census was 93.
Record review of the facility's Showers/Bathing Policy, dated 12/10/2021, showed:
- Showers/Baths will be offered at a frequency of at least two times per week, unless otherwise requested;
- If a resident has a specific preference related to bathing/showering this will be identified and staff will assist as needed;
- Staff will assist with bathing/showering as needed to ensure residents remain clean and odor free;
- Residents who are independent with bathing/showering will be monitored for compliance;
- Residents that resist bathing/showering will be added to their comprehensive care plan.
1. Record review of Resident #1's Level 1 Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care, which consists of two potential levels of assessment), dated 4/30/2021, showed:
- Met the federal definition of serious mental illness, but did not require specialized services;
- Diagnoses of Major Depressive Disorder (a mental disease characterized by low mood, low self-esteem and loss of interest), Personality Disorder (a mental disorder of rigid thinking and unhealthy thoughts); Major Neurocognitive Disorder (a new term for dementia); Generalized Anxiety Disorder; and long history of suicidal thoughts;
- Qualified for a Level 2 screening (more in depth assessment of the PASRR).
Review of Resident #1's Level 2 PASRR screening, dated 5/11/2021, showed:
- Assessed needs included maximum assistance with activities of daily living (ADLs), especially bathing;
- Referral notes included poor judgment and poor insight;
- The resident required physical assist of staff for bathing.
Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 3/17/2023, showed:
- admission to the facility on 5/14/2021;
- Severe cognition impairment;
- A need for physical assistance with bathing/showering;
- Diagnoses of anxiety, depression, Parkinson's Disease (a chronic degenerative disorder of the central nervous system), and Traumatic Brain Injury (TBI - a brain injury caused by an outside force).
Record review of Resident #1's care plan, last revised on 3/21/2023, showed:
- An increased risk for falls;
- An ADL self-care performance deficit related to Parkinson's diagnosis. Staff will assist with bathing, shaving, dressing and incontinent care as needed;
- Impaired cognitive function and thought process.
The resident's care plan did not address the resident's history of suicidal ideations or unsupervised bathing.
During an interview on 3/27/2023 at 1:15 P.M., CNA B said most of the residents on the unit are mobile and able to come and go to the shower room as they please, to use the bathroom or to take a shower. CNA B did not know Resident #1's care plan indicated he/she required assistance with bathing.
During an interview on 3/27/2023 at 6:00 P.M., Licensed Practical Nurse (LPN) D said he/she worked with the resident often and had no idea Resident #1 was cognitively impaired. The LPN was not aware of the diagnoses in the MDS and care plan or that Resident #1 was care planned for assistance with bathing. LPN D said the resident bathed unsupervised and unassisted.
During an interview on 3/27/2023 at 12:30 P.M., the Administrator (ADM) said she did not know what the resident's PASRR said, he/she had never looked at it. The ADM said the PASRR information should be part of the care plan.
During an interview on 3/27/2023 at 2:45 P.M., the resident's physician said the resident required supervision and should never have been allowed to shower or bathe alone.
During an interview on 3/28/2023 at 11:00 A.M., the Social Services Director (SSD) said he/she and the MDS Coordinator look over the PASSR and create a care plan. The SSD said he/she does not know how the resident's issues were missed.
Dec 2021
49 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess, monitor, and ensure a resident (Resident #1) with a surgica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess, monitor, and ensure a resident (Resident #1) with a surgical incision received treatment and services to promote healing and prevent infection; failed to ensure the resident attended follow up appointments for post-surgical dressing changes or contact the physician for incision care orders; failed to obtain the resident's laboratory (lab) tests as ordered by the physician. These deficient practices resulted in Resident #1 developing an infection and re-injury, requiring a prolonged hospital stay and antibiotic therapy. The facility also failed to provide appropriate care and treatment necessary to prevent the occurrence of constipation (a condition with a difficulty of emptying the bowels) and follow the bowel protocol for one resident (Resident #49) and failed to obtain physician orders for skin care and provide services to promote healing and to prevent infection for one resident (Resident #334) out of 20 sampled residents. The facility's census was 81.
The administrator was notified on 11/18/21 at 11:30 AM of an Immediate Jeopardy (IJ) which began on 10/8/21. The IJ was removed on 11/18/21, as confirmed by surveyor onsite verification.
1. The facility did not provide a policy regarding the care and monitoring of surgical incisions.
Record review of the facility's policy titled Medical Appointments and Transportation policy, dated 10/09/18, showed:
- The Nursing and or Designee will be responsible for the scheduling of medical appointments for those not scheduled by a resident and/or their responsible party/family;
- Nursing and or Designee will arrange transportation to/from medical appointment;
- When appointments and transportation are scheduled they will be documented in the designated appointment book;
- Nursing and or Designee every Friday places updated transportation schedule at nurse station for upcoming week. Nursing Department communicates upcoming appointments to residents on their assigned halls;
- The facility staff will make every effort to get a resident to all of their scheduled medical appointments, however, if an appointment is missed due to transportation issues, inclement weather, and or other reasons beyond the facility's control, the staff will reschedule the appointment at the earliest available date.
Record review of the facility's policy titled Laboratory Services Policy, undated, showed:
- The facility will provide or obtain laboratory services to meet the needs of the residents;
- The facility is responsible for the quality and timeliness of the services;
- The nurse/designee will review physician orders for any new orders for laboratory services and schedule with the lab provider;
- A copy will be placed in the resident's record with the name and address of the testing laboratory.
Record review of Resident #1's Hospital Physician Progress Note, dated 10/5/21, showed:
- Status post open reduction and internal fixation (ORIF: surgical procedure used to repair fractures) right patella (knee cap);
- Knee does not appear infected;
- Dressing change today with PICO (a negative pressure wound therapy used to draw out excess fluid from surgical incision) dressing.
Record review of the resident's Hospital discharge instructions, dated [DATE], showed:
- Surgical site: right knee, PICO dressing to stay on until follow up with physician, keep dry and intact;
- Follow up appointment with physician on Monday (10/11/21) at 10:30 A.M.;
- Have primary care physician round on resident in one week. Draw lab: complete blood count (CBC), comprehensive metabolic panel (CMP), and magnesium (MAG) before visit.
Record review of the resident's interim care plan, effective date 9/17/21, showed:
- Resident admitted to the facility on [DATE];
- Resident re-admitted to the facility on [DATE];
- No updates to the care plan to include the resident's right knee surgical incision;
- No interventions on the care plan to assess, monitor, or care for the resident's incision.
Record review of the resident's comprehensive care plan, dated 11/15/21, showed the care plan was completed after the resident was re-admitted to the hospital on [DATE].
Record review of the resident's Physician's Order Sheet (POS), dated 11/17/21, showed:
- re-admitted to the facility on [DATE];
- Diagnoses of chronic obstructive pulmonary disease (COPD, lung disease), hypertension, anxiety, and depression;
- An order on 10/08/21 to keep PICO dressing on, dry, and intact until appointment with physician;
- No orders for lab tests.
Record review of the resident's September, October, and November 2021 Treatment Administration Record (TAR) showed no documentation of incision monitoring or care.
Record review of the resident's September, October, and November 2021 progress notes, showed:
- On 10/08/21 at 10:16 A.M., the resident returned to the facility with PICO drain on right knee incision site. Follow up with the physician on 10/11/21 at 10:30 A.M.;
- On 10/19/21, NP visit note, resident status post ORIF to right lower extremity (RLE), orthopedic following. No documentation of lab tests performed or reviewed;
- On 11/9/21 at 9:47 A.M., the resident has PICO dressing on from right total knee repair, PICO pump was laying on the resident's night stand, this nurse asked how long has it been off and the resident stated it had been a few days. The nurse called the physician's office and waiting to hear back;
- No documentation of assessments, monitoring, or care of the resident's surgical incision;
- No documentation of reasons why the resident did not attend post-surgical follow up appointments or any communication with the physician for incision care orders;
- No documentation of reason lab tests not obtained as ordered.
Record review of the physician's office log notes, showed:
- No show for appointment on 10/11/21 at 10:30 A.M.;
- The facility's receptionist on 10/21/21 called to cancel the resident's appointment on 10/22/21 due to the resident being in quarantine. The physician's office requested to make a telehealth visit and was transferred to the social worker and did not get an answer;
- The facility's receptionist called on 11/3/21 and an appointment was scheduled for 11/11/21.
Record review of the resident's Hospital History and Physical, dated 11/11/21, showed:
- admitted to the hospital on [DATE];
- Chief complaint of right knee infection with wound dehiscence (a surgical complication where the incision reopens);
- The resident was seen by a physician today. The resident's knee was scabbed over and had wires sticking out of it and had surrounding swelling and erythema (redness);
- The resident reports that there had been no changes to his/her bandages (while in the nursing home);
- Wound care specialist consulted and debrided (removed) all the eschar (dead skin tissue).
Record review of the resident's Hospital Consultant Note, dated 11/11/21, showed:
- The resident is post ORIF of the right patella over six weeks ago and had multiple cancellations of his/her clinic visits;
- The resident arrived at the clinic today with the same dressing on and sutures were not removed;
- There was erythema around the knee;
- There was wound dehiscence with hardware exposed;
- The area of dehiscence was approximately one centimeter with hardware exposed which was 18 gauge wire;
- The fracture had lost reduction (alignment) as well;
- The resident admitted to the hospital for wound care and IV antibiotics as did appear to have cellulitis (skin infection) and wound dehiscence;
- Would like wound to heal before doing hardware removal and then have to determine possible ORIF versus patellectomy (removal of the knee cap).
Record review of the resident's Hospital Progress Notes, dated 11/15/21, showed:
- Infected patellar hardware;
- Evaluation for long-term acute care as the patient will need 2-3 weeks of IV antibiotics on top of need for skin culture and wound healing prior to orthopedic evaluation for hardware removal.
Record review of the resident's November 2021 progress notes, showed:
- On 11/15/21 at 2:37 P.M., the hospital called and informed the facility that the resident was being transferred to a critical care hospital for long term intravenous (IV) therapy;
Record review of the resident's Hospital Discharge Summary/Transfer Report, dated 11/16/21, showed:
- The resident had underwent ORIF on 9/30/21;
- The resident discharged to the nursing facility;
- The resident had poor wound care and follow up with noncompliance;
- The resident was not seen by orthopedic until 11/11/21;
- The resident was noted to have no bandage changes and eschar formation which was debrided;
- Presumed osteomyelitis (bone infection) and bone exposure underneath;
- The resident agreed to transfer to an acute long-term care facility with IV antibiotic therapy;
- Will follow up with orthopedic and decide on when eschar and skin has healed over in the next ten days to two weeks;
- Considerations for repeat surgery and potential hardware removal versus complete patella removal will be decided at a later date.
During an interview on 11/17/21 at 3:50 P.M., Licensed Practical Nurse (LPN) A said he/she was the resident's re-admission nurse on 10/08/21. The resident had an order for RLE dressing to stay in place until a physician's appointment on 10/11/21. A note was left for the receptionist to schedule transportation to the appointment. Until, recently, he/she was not aware the resident did not go the appointment. LPN A assessed the resident's incision on re-admission by pulling back the dressing on the resident's right knee. The incision was intact with sutures. This was the only time he/she assessed the resident's incision because the resident had no orders to do so. If any assessments, monitoring, or dressing changes had been completed, he/she would have documented in the resident's progress notes. He/she did not know why the resident's lab tests were not completed and unsure why orders were not on the resident's POS. The lab test orders should have been entered into the computer. The Minimum Data Set (MDS: a federally mandated assessment instrument required to be completed by facility staff) nurse is responsible for developing and updating a resident's care plan.
During an interview on 11/18/21 at 8:45 A.M., Receptionist B said he/she was not made aware of the resident's appointment on 10/11/21 until 10/14/21. The physician's office was called and the appointment rescheduled for 10/22/21. This appointment was canceled due to the resident being on quarantine. Since it was unknown how long the resident would be on quarantine, the appointment was not rescheduled. He/she asked a facility staff member if a telehealth visit was an option, but was told no due to being a privacy issue. When the resident was done with quarantine, the appointment was rescheduled for 11/11/21. He/she said each week the nursing stations are provided a calendar with resident appointments for the week and rely on nursing staff to notify him/her of any resident appointments not scheduled by him/her.
During an interview on 11/18/21 at 9:50 A.M., Certified Nurse Aide (CNA) C said sometime last week, part of the resident's RLE dressing was lying on the bedside table. The resident said he/she had not seen the surgeon since returning from the hospital. CNA C checked the appointment calendars and did not see any appointments scheduled for the resident. The nurse was notified. On 11/11/21, CNA C assisted the resident to a physician appointment. The physician said the resident's knee looked infected and had parts of the hardware sticking out. The physician said the resident's dressing had not been changed since discharge from the hospital. The resident was admitted to the hospital from the physician's office.
During an interview on 11/18/21 at 11:00 A.M., LPN D said he/she had not assessed, monitored, or changed the dressing on the resident's RLE incision. He/she did not contact the physician for any incision care orders. Any care or monitoring would have been documented in the resident's progress notes. The physician's office called on 11/11/21 and said the resident had missed several appointments and was being direct admitted to the hospital. LPN D said prior to the phone call he/she was not aware of the missed appointments. The facility has a weekly log of appointments. Nursing staff are responsible for notifying the receptionist of any new resident appointments so transportation can be arranged. The nurse that received orders for lab testing is responsible for entering into the computer. The computer gives a reminder when lab test due. LPN D did not know who updated resident care plans.
During a telephone interview on 11/18/21 at 2:00 P.M., LPN E said he/she had not assessed, monitored, or changed the resident's RLE dressing because the resident had an order not to remove the dressing. Any care would have been documented in the resident's progress notes. He/she was not aware of the resident missing any appointments nor did he/she call the physician's office for orders. The nurse who received a new physician appointment should notify the scheduler.
During a telephone interview on 11/19/21 at 11:25 A.M., Registered Nurse (RN) F said the resident had an order for RLE dressing to stay in place so he/she did not assess or monitor the resident's incision. He/she did not remove or change the resident's dressing. Any care performed would have been documented in the resident's progress notes. Care plans are developed and updated by the MDS staff not the nurses. The nurse who received lab testing orders is responsible for entering the order into the computer.
During an interview on 11/18/21 at 2:45 P.M., the Director of Nursing (DON) said she expects nurses to ensure residents attend physician appointments and follow up with physicians for orders. Nurses are responsible for communicating with the receptionist to schedule transportation to appointments. She expects nurses to assess and monitor a resident's surgical incision site at least daily. Nurses are expected to document any assessments, monitoring, care, or communication with physician's office. Nurses are expected to follow physician's orders and follow up on lab test results. Nurses should pass on in report any resident changes and update care plan within 24 hours. She expects care plans to be completed in a timely manner.
During an interview on 11/18/21 at 4:00 P.M., the Administrator said she expects staff to follow physician's orders. Nurses are expected to monitor surgical incisions and to document. Nurses should contact the physician for care orders. Staff are expected to make sure resident's attend appointments.
During a telephone interview on 11/22/21 at 8:33 A.M., the Physician said the resident had on ORIF of right knee on 9/30/21. During the resident's stay in the hospital, a PICO dressing was placed. He/she likes to follow up with the resident in the office within 7 days of the dressing being placed. At the appointment, he/she would have removed the dressing and determined if a new PICO dressing would be placed or another type of dressing. The resident missed several appointments. When the resident arrived at his/her office on 11/11/21, the original dressing was still on the resident's right knee. The resident's incision was infected, open with wires sticking out, and the sutures had not been removed. The sutures should have been removed 14 days after placement. The facility staff did not contact him/her for any care orders. The resident will be on IV antibiotics for a couple of weeks and will need additional surgery as a result of the facility not monitoring, providing care, and ensuring the resident attended appointment.
2. Record review of the facility's policy titled Bowel policy, updated March 2018, showed:
- Each resident will be assessed for 72 hours for bowel and bladder voiding patterns on admission, quarterly and with a significant change in elimination patterns with evaluation for feasibility in retraining for bowel and/or bladder control;
- The licensed nurse will gather information from the chart, the resident's family/representative, staff members, from resident observations, and from review of the 72 hour voiding patterns;
- The information will be used to complete the bowel and bladder assessment;
- The residents plan of care will be developed to address the issue, goals, and appropriate interventions.
Record review of Resident #49's POS, dated October 2021, showed:
- Diagnosis of constipation;
- An order for milk of magnesia (a laxative) 30 milliliters (ml) every 24 hours as needed for constipation, dated 8/24/21.
Record review of the resident's Medication Administration Record (MAR), dated October 2021, showed:
- An order for milk of magnesia 30 ml every 24 hours as needed for constipation, dated 8/24/21;
- No documentation the resident received the medication for the 31 days.
Record review of the resident's bowel movement (BM) records, dated 9/21 - 11/21, showed:
- No documentation of BMs from 9/1/21 - 9/30/21 (30 days);
- No documentation of BMs from 10/1/21 - 10/8/21, 10/11/21 - 10/14/21 (four days), 10/21/21 - 10/23/21 (three days);
- No documentation of BMs from 11/6/21 - 11/16/21 (11 days).
Record review of the resident's hospital medical record showed:
- The resident admitted to the hospital on [DATE] - 11/29/21;
- Diagnoses of fecal impaction (hardened stool that becomes stuck in the rectum or lower colon due to chronic constipation), urinary tract infection (UTI: an infection of the urinary system), and persistent hypoglycemia (a deficiency of glucose in the bloodstream);
- Received three rounds of GoLytely (a laxative) to treat the fecal impaction while in the hospital.
Record review of the resident's POS, dated November 2021, showed:
- An order for docusate sodium (a stool softener) 100 milligram (mg) two times daily for constipation, dated 11/29/21;
- An order for milk of magnesia 30 ml every 24 hours as needed for constipation, dated 11/29/21;
- An order for miralax (a laxative) 17 grams (gm) daily for constipation, dated 11/29/21.
During an interview on 12/8/21 at 2:16 P.M., Registered Nurse (RN) F said the resident BMs are recorded on the BM forms in the BM book. Staff should record whether a resident had a BM, if so, the size, or if they had no BM each shift. The nurses should check the BM book but he/she isn't sure if it's being done.
During an interview on 12/8/21 at 2:40 P.M., Certified Nurse Assistant (CNA) P said there is a resident BM book the CNAs document the residents' BMs in. If a resident hasn't had a BM in two days, they are to let the certified medication technician (CMT) know. If a resident hasn't had a BM in three days, again, the CNA's are to let the CMT know. He/she works the memory care unit where Resident #49 resides quite often, and he/she is unaware of the resident not having BM's documented and being treated for a fecal impaction in the hospital. Each staff should document each shift whether a resident had a BM, along with size, or not.
During an interview on 12/9/21 at 11:57 A.M., the Administrator said she would expect the staff to monitor and record the residents' BMs. The CNAs and nurses are responsible for the BM monitoring and documentation. She would expect the resident's physician to be notified if a resident hadn't had a BM in a couple of days, depending on the resident's signs and symptoms.
3. Record review of Resident #334's medical record showed:
- admission date of 4/26/19;
- Diagnoses include bipolar disorder (mental disorder that causes unusual shifts in mood), Alzheimer's disease (progressive mental deterioration), diabetes mellitus (condition that affects the way the body processes blood sugar), major depressive disorder-recurrent (long-term loss of pleasure or interest in life), and chronic kidney disease (a gradual loss of kidney function);
- The annual MDS, dated [DATE], showed BIMS score to be not evaluated;
- Extensive assistance for mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Frequently incontinent of bowel and bladder.
Observation on 11/30/21 at 10:37 A.M., showed the resident's head has crusty growths and scabs over the top and down the resident's forehead. One bandaid placed so that the adhesive is on part of the scabbed area.
During an interview on 11/30/21 at 10:37 A.M., the resident said the staff do not clean his/her head everyday.
During an interview on 11/30/21 at 4:00 P.M., RN F said the resident has hyperkeratosis (a condition marked by thickening of the outer layer of the skin) and sometimes it breaks open. He/she has it pretty much all over his/her head, I don't think we have any orders to do anything, let me double check. While checking, the nurse said the doctor saw the resident last month and commented on what it was but did not give any specific orders. No one asked for any.
Observations showed:
- On 12/1/21 at 9:33 A.M., on 12/2/21 at 9:20 A.M., and on 12/7/21 at 9:40 A.M., the resident's head crusty growths and scabs over the top and down the resident's forehead. One bandaid placed so that the adhesive is on the scabbed area;
- On 12/8/21 at 8:56 A.M., the resident sat with head of bed up. The resident's head crusty growths and scabs over the top and down the resident's forehead. One bandaid placed so that the adhesive is on the scabbed area.
During an interview and observation on 12/8/21 at 8:56 A.M., the Director of Nursing (DON) said she was unaware of the band aid being in place that long. She said that is not acceptable, she is working on getting a wound care nurse for the facility and she will make sure it is addressed.
NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents (Resident #12 and #33) out of 20 sampled resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents (Resident #12 and #33) out of 20 sampled residents received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility's census was 81.
Record review of the facility's undated policy titled, Pain Management Policy, showed:
- The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being;
- Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status;
- Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: loss of function, decline in activity level, resisting care, striking out, increased restlessness, facial expressions, change in behavior, depressed mood, loss of appetite, sleeping poorly, sighing, groaning, crying, and breathing heavily;
- Reassess residents with pain regularly based on the facility's established intervals;
- If re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated.
1. Record review of Resident #12's medical record showed:
- admission date of 2/23/21;
- Diagnoses included pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
- The quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 6/6/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 which indicated the resident to be cognitively intact.
Record review of the resident's Physician's Order Sheet (POS), dated 12/1/21, showed:
- An order, dated 2/23/21, to assess pain four times a day;
- An order, dated 4/28/21, for oxycodone HCl (a medication used to treat severe pain) 20 milligram (mg), scheduled every six hours for pain.
Record review of the resident's comprehensive care plan, last updated 9/29/21, showed:
- Problem: I have a diagnosis of pain, I have scheduled and as needed pain medication ordered;
- Goal: My pain will be maintained at an acceptable level for me;
- Approaches: Administer my ordered pain medication as needed, monitor for effectiveness, ask me frequently if I am having pain, offer alternative pain interventions as needed- music, relaxation techniques, deep breathing, etc.
Record review of the resident's Medication Administration Record (MAR):
- Dated 10/1/21 - 10/31/21 showed oxycodone 20 mg not administered 17 out of 124 opportunities without a reason documented. Four out of 124 opportunities to assess pain missed without a reason documented;
- Dated 11/1/21 - 11/30/21 showed oxycodone 20 mg not administered 18 out of 120 opportunities without a reason documented. One of 120 opportunities to assess pain missed without a reason documented;
- Dated 12/1/21 - 12/1/21 showed oxycodone 20 mg not administered 2 out of 4 opportunities without a reason documented. Three of four opportunities to assess pain missed without a reason documented.
During an interview on 11/30/21 at 8:45 A.M., the resident said he/she has been a resident about seven months and has not seen a doctor, only a nurse practitioner (NP). The resident feels he/she needs more pain medication, that is why he/she agreed to palliative care (PC: an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex illnesses). The resident said he/she has pain in all joints due to DM neuropathy (a disease of the nerves causing tingling, burning or loss of sensation). He/she has taken hydrocodone (pain medication) for years and the doctor has never increased his/her dose.
During an interview on 11/30/21 at 10:05 A.M., the resident stated his/her pain is not controlled and they refuse to change or increase his/her pain medication. He/she agreed to PC so that they could get his/her pain under control but they haven't changed anything. He/she just feels like giving up and going on hospice (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) if they can't get the pain under control.
During an interview on 12/1/21 at 4:14 P.M., Licensed Practical Nurse (LPN) M said the resident is on PC but he/she does not know the date the resident was admitted and did not make a note. LPN M was there that day and they told the resident to call if anything changes, his/her Primary Care Provider would manage his/her pain medications. They made no changes.
During an interview on 12/2/21 at 10:04 A.M., the LPN with the PC agency said they do not replace a current physician, the nurse practitioner (NP) sees the resident and makes recommendations for pain management. The NP has seen Resident #12 one time and did not recommend any changes to the current order. The resident is supposed to be seen again 12/15/21 but they can move the appointment sooner. The LPN will talk to the NP when he/she returns to the office.
During an interview on 12/7/21 at 9:41 A.M., the resident stated he/she went to the hospital this weekend because his/her blood pressure went up and oxygen saturation was below 90%. The resident stated he/she has tried to reach palliative care for his/her pain management and has not heard back. His/her pain is not under control and the resident wants someone to help him/her, it is getting worse.
2. Record review of Resident #33's medical record showed:
- Original admission date 4/22/19 with readmission date of 11/12/21;
- Diagnoses include chronic pain (persistent pain that lasts weeks to years), major depressive disorder (long-term loss of pleasure or interest in life), Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), COPD, transient cerebral ischemic attack (TIA: a neurologic deficit that produces stroke symptoms that resolve within 24 hours), atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries causing obstruction of blood flow), and mood disorder (a condition which causes a person's emotional state to be distorted and interferes with the ability to function).
Record review of the resident's annual MDS dated [DATE] showed:
- The BIMS score of 9 out of 15, moderate cognitively intact;
- Section J 0100 showed the resident on a scheduled pain regimen, not received prn medications, and not received non-medication interventions;
- Section J 0200 showed the resident should be interviewed for pain assessment;
- Section J 0300 showed yes for pain presence;
- Section J 0400 frequent pain;
- Section J 0500 pain makes it hard to sleep at night;
- Section J 0600 rated pain as 6 out of 10;
- Section J 0700 showed should the staff assessment for pain be conducted and the answer was no.
Record review of the resident's MAR, dated 9/1/21 through 9/30/21, showed the resident received acetaminophen 650 mg on 9/4/21 at 8:38 P.M. for pain rated 5.
Record review of the resident's quarterly MDS dated [DATE] showed:
- The BIMS score of 10 out of 15, moderate cognitively intact;
- Section J 0100 showed the resident not on a scheduled pain regimen, not received prn medications, and not received non-medication interventions
- Section J 0200 showed the resident should be interviewed for pain assessment;
- Section J 0300 showed no for pain presence;
- Section J 0400 through Section J 0700 no documentation.
Record review of the resident's MAR, dated 10/1/21 through 10/31/21, showed the resident received prn acetaminophen 650 mg:
- On 10/16/21, at 12:21 A.M. for pain rated 8 and at 4:33 P.M. for pain rated 8;
- On 10/17/21 at 2:41 P.M. for pain rated 8;
- On 10/18/21 at 8:16 A.M. for pain rated 8;
- On 10/24/21 at 7:15 P.M. for pain rated 8;
- On 10/28/21 at 4:26 A.M. for pain rated 4;
- On 10/31/21 at 5:13 A.M. for pain rated 5 and at 11:50 P.M. for pain rated 3.
Record review of the resident's MAR, dated 11/1/21 through 11/30/21, showed the resident received acetaminophen 650 mg on 11/2/21 at 8:57 A.M. for pain rated 2.
Record review of the resident's November and December 2021 POS's showed:
- An order, dated 11/12/21, to assess and monitor resident for pain four times daily with medication pass;
- An order, dated 11/12/21 for acetaminophen (mild pain medication) 650 mg every four hours as needed (prn) for fever or pain;
- An order, dated 11/12/21, for Gabapentin (anticonvulsant and nerve pain medication) 300 mg three times daily for neuropathy (a disease of the nerves causing tingling, burning or loss of sensation, chronic pain);
- An order, dated 11/13/21, for Percocet (to treat moderate to moderately severe pain) 5-325 mg every six hours prn for pain.
Record review of the resident's Treatment Administration Record (TAR), dated 11/1/21 through 11/30/21, showed:
- An order, dated 11/12/21, to assess and monitor resident for pain four times daily with medication pass at 9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M. starting on 11/12/21 at 5:00 P.M.,
- The resident not assessed for pain on 11/12/21 at 5:00 P.M. or 9:00 P.M., 11/13/21 at 5:00 P.M., 11/16/21 at 9:00 P.M., and 11/23/21 at 5:00 P.M. Five opportunities missed;
- On 11/13/21 at 9:00 A.M. resident rated pain 3 (on a scale from 0-10, with 0 being no pain and 10 being the worst pain) and at 12:00 P.M. resident rated pain 9, no prn pain medication given;
- On 11/15/21 at 12:00 P.M. resident rated pain 2, acetaminophen 650 mg given at 4:20 P.M.;
- On 11/16/21 at 5:00 P.M. resident rated pain 3, no prn pain medication given;
- On 11/17/21 at 12:00 P.M. resident rated pain 4 and at 5:00 P.M. resident rated pain 1, no prn pain medication given;
- On 11/18/21 at 9:00 A.M. resident rated pain 2, at 12:00 P.M. resident rated pain 5, no prn pain medication given;
- On 11/21/21 at 9:00 A.M. resident rated pain 9, at 12:00 P.M. resident rated pain 9, and at 9:00 P.M. resident rated pain 9, no prn pain medication given;
- On 11/22/21 at 9:00 A.M. resident rated pain 3, at 12:00 P.M. resident rated pain 2. At 4:27 P.M., resident rated pain 8, acetaminophen 650 mg given;
- On 11/23/21 at 12:00 P.M. resident rated pain 5, no prn medication given;
- On 11/24/21 at 9:00 A.M. resident rated pain 2 and at 5:00 P.M. resident rated pain 4, Percocet 5-325 mg given at 8:28 P.M.;
- On 11/27/21 at 9:00 A.M. resident rated pain 4, at 12:00 P.M. resident rated pain 4, and at 5:00 P.M. resident rated pain 5, prn Percocet 5-325 mg given at 6:12 P.M.;
- On 11/28/21 at 9:00 A.M. resident rated pain 2, at 12:00 P.M. resident rated pain 3, no prn pain medication given;
- On 11/29/21 at 9:00 A.M. resident rated pain 8, at 12:00 P.M. resident rated pain 1, no prn medication given.
Record review of the resident's comprehensive care plan last updated 11/30/21, showed the care plan did not address pain and interventions.
During an interview on 11/30/21 at 9:45 A.M., the resident said he/she has to beg for pain medicine.
During an interview on 12/08/21 at 10:55 A.M., the resident said his/her pain is about medium. The resident broke his/her leg and it hurts sometimes. The resident fell one night going to the bathroom. The resident doesn't always get pain medicine because no one ever comes in room. Resident #33 said, You can't ask for pain medicine if you don't see anybody.
During an interview on 12/9/21 at 11:57 A.M., the Administrator, Director of Nursing, and Director of Operations said they would expect pain assessments to be completed as ordered. They would expect the comprehensive care plan to include each area of concern. The MDS nurse is responsible for completing the care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the resident and/or the resident's responsible party (RP) were invited to participate in all aspects of person-centered care plannin...
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Based on interview and record review, the facility failed to ensure the resident and/or the resident's responsible party (RP) were invited to participate in all aspects of person-centered care planning for one resident (Resident #57) outside of 20 sampled residents. The facility's census was 81.
Record review of the facility's policy titled, The Estates, regarding care plans, updated 7/20, showed:
- A care plan shall be used in developing the residents' daily care routine and will be available to ensure the best person-centered care is provided to our residents;
- Care plan meeting will be held quarterly with the interdisciplinary team, resident, and responsible party or guardian.
Record review of Resident #57's medical record showed:
- admission date of 2/14/19;
- The resident to be his/her own responsible party;
- Diagnoses included multiple sclerosis (MS: a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain.
- The quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 5/5/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 which indicated the resident to be cognitively intact.
Record review of the guardianship document, located in the electronic record miscellaneous documents, dated 9/13/21, showed the resident to have a RP with no phone number listed.
During an interview on 12/1/21 at 9:15 A.M., the resident said he/she has never been invited to a care plan meeting.
During an interview on 12/1/21 at 9:48 A.M., the SW said the resident has a legal guardian. The SW will correct the resident's medical record to include the RP with a phone number.
During an interview on 12/01/21 at 7:47 P.M., the RP said he/she has been trying for months to communicate with the facility about the resident's care and condition. No one will call back and no one will help him/her make contact with the resident, even though the RP pays for a phone for the resident to use. The facility sent a care plan to the RP dated March 2021 with a diagnosis of major psychosis (a mental disorder characterized by a disconnection from reality), no diagnosis of MS and no plan to meet the resident's physical needs. The facility staff do not call about anything. The RP said he/she has never participated in a care plan meeting. He/she knows nothing of what is going on.
During an interview on 12/9/21 at 11:57 A.M., the Director of Operations said the resident and/or RP should be included in the care planning process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0555
(Tag F0555)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to allow one resident (Resident #12) out of 20 sampled residents to choose his/her attending physician. The facility's census was 81.
Record r...
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Based on interview and record review, the facility failed to allow one resident (Resident #12) out of 20 sampled residents to choose his/her attending physician. The facility's census was 81.
Record review of the facility's policy titled, Resident Rights Policy, dated 12/1/19, showed:
- It is the policy of this facility to provide quality healthcare through communication, respect, and sensitivity between the residents and those who provide them care. Our facility strives to promote the exercise of rights for each resident, even if he or she is determined to be incompetent, should be able to assert these rights based on his or her degree of capability;
- Residents can choose their own doctor. As long as the physician meets the facility's privilege requirements, follows the regulations related to the frequency of visits, restraints, psychotropic medications, and other medication recommendations.
Record review of Resident #12's medical record showed:
- admission date of 2/23/21;
- Diagnoses include pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should) and diabetes mellitus (DM: condition that affects the way the body processes blood sugar);
- The admission Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 3/6/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15, which indicated the resident to be cognitively intact.
During an interview on 11/30/21 at 8:45 A.M., the resident said he/she has been a resident about seven months and has not seen a doctor, only a nurse practitioner (NP). The resident feels the doctor makes decisions for the resident, but has no business making any decision for the resident since the doctor hasn't ever seen the resident. Resident #12 feels he/she needs more pain medication, which is why he/she agreed to palliative care (PC: an interdisciplinary medical care giving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex illnesses). The NP and other nurses have told the resident that the Drug Enforcement Agency (DEA: government program to enforce controlled substances laws/regulations) would review the facility's records, therefore the facility staff cannot give the resident more pain medication. The resident said he/she has pain in all joints due to DM neuropathy (a disease of the nerves causing tingling, burning or loss of sensation). He/she has taken hydrocodone (pain medication) for years and the doctor has never increased his/her dose. The resident said he/she wants a different doctor.
During an interview on 12/1/21 at 4:03 P.M., Licensed Practical Nurse (LPN) M said the palliative care nurse said they would meet with the resident one time a month and the primary care provider would be consulted for medication orders. On the first visit there were no changes made to the resident's pain medications. LPN M said he/she forgot to put a note in the chart about the plan.
During an interview on 12/2/21 at 9:45 A.M., Resident #12 said he/she thought by agreeing to PC, he/she would get another doctor. The facility staff nurse told the resident that the facility doctor would take care of him/her. The resident is not satisfied with the doctor's care, has never seen the doctor and has told the nurses several times. He/she is in so much pain and isn't getting help for it. He/she may just give up and go on hospice (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life).
During an interview on 12/2/21 at 10:00 A.M., the LPN with the palliative care provider said the nurse practitioner (NP) has seen the resident one time. The NP makes recommendations but they allow the primary care provider to manage the pain medication. There were no changes made to pain medications on the first visit. The NP is scheduled to see the resident for the second visit on 12/15/21 but the LPN will see if that visit can be moved to a sooner date or if the NP can make any recommendation over the phone.
Record review of the resident's nurse progress notes, dated 2/23/21 through 12/2/21, showed no notes regarding the resident's desire to change physicians.
During an interview on 12/9/21 at 11:57 A.M., the Administrator, Director of Nursing, and the Director of Operations said they would expect a resident to be able to choose their own doctor. They were not aware that the resident wants a different doctor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one resident (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one resident (Resident #76) out of 20 sampled residents and one additional resident (Resident #57) outside the sample. The facility's census was 81.
1. Record review of the facility's policy titled, Resident Rights Policy, last updated 12/1/19, showed:
- It is the policy of this facility to provide quality healthcare through communication, respect, and sensitivity between the residents and those who provide them care. Our facility strives to promote the exercise of rights for each resident, even if he or she is determined to be incompetent, should be able to assert these rights based on his or her degree of capability;
- Make choices about his or her own life subject to the facility's rules, as long as those rules do not violate a regulatory requirement;
- Access a telephone where calls can be made privately;
- Residents have a right to voice their grievances;
- Receive services that accommodate individual needs and preferences as long as it doesn't endanger anyone else.
2. Record review of Resident #57's medical record showed:
- admission date of 2/14/19;
- The resident to be his/her own responsible party (RP);
- A guardianship document, dated 9/13/21, to show a family member designated to be the RP;
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain;
- The quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 5/5/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 indicating the resident to be cognitively intact.
- Extensive assistance for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Always incontinent of bowel and bladder.
Record review of the resident's comprehensive care plan, last updated 10/21/21, showed direction for staff to do the following interventions:
- Provide finger foods when using utensils is difficult;
- Provide a mechanical soft diet and finger foods in a divided plate with a cup and lid. Let the resident make all of his/her food choices;
- Tell the resident where his/her things are and be consistent. Tell the resident what food items are and where they are located on the plate, the placement of napkin, drinks, silverware and TV remote on bedside table;
- Encourage resident to participate in conversation with staff and/or other residents daily. Assist the resident with his/her phone as needed. Provide as many opportunities as possible which allow the resident to have control over his/her environment and care delivery.
Observations showed:
- On 11/29/21 at 1:10 P.M., the resident lay in bed, the bedside table with spilled liquid, one plastic cup without a lid, and an open carton of milk, the sheet stained with brown liquid and food;
- On 12/1/21 at 9:15 A.M., the resident lay in bed, a napkin on his/her chest with spilled red gelatin, a mug of yellow broth without a lid, two open containers of jell, red stains on gown and sheet;
- On 12/7/21 at 9:30 A.M., the resident lay in bed, the bedside table with spilled clear liquid on it, a foam cup without a lid with clear liquid in it;
- On 12/8/21 at 10:49 A.M., the resident lay in bed with popcorn on his/her chest, the sheet stained with brown liquid and food;
- On 12/08/21 at 1:55 PM., the resident lay in bed with a towel laid over his/her chest, lunch of ravioli with sauce, corn, and dessert with graham cracker crust, served on an undivided plate, smeared over the bedside tray, the sheet and bed, and food in the resident's hair. The resident upset, talked loud, and complained about the situation he/she is in.
During an interview on 11/29/21 at 1:10 P.M., the resident said It is like a prison here, I have told them I want to leave and no one will listen. They always say they will be back and they never come back.
During an interview on 12/7/21 at 1:55 P.M., the resident said he/she was given ravioli for lunch and a fork, but he/she needs a spoon or finger foods because of his/her hands. He/she said I have told them for over a year what I need and they won't do it. I tell them I need to know where the food is so I can figure out how to eat it because I can't see it. They just set it down and leave.
3. Record review of Resident #76's medical record showed:
- admission date of 4/8/19;
- Diagnoses include venous insufficiency (difficulty with blood returning to the heart from the legs), depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic pain (pain that is ongoing and usually lasts longer than six months);
-- The quarterly MDS, dated [DATE], showed the BIMS score to be 10 out of 15 indicating the resident to be moderately cognitively impaired.
Record review of the resident's comprehensive care plan, last updated 7/5/21, showed:
- Problem: The resident wants the urinal to sit on the beside table even during meals;
- Goal: To assure area/bedside table is clean throughout review period;
- Approaches: Offer to clean and cover urinal, and staff to empty urinal before meals.
Observations showed:
- On 11/29/21 at 1:31 P.M., the resident sat at beside in a wheelchair, bedside table in front of resident with dried liquid and food on it, and a urinal sat on table;
- On 11/30/21 at 8:37 A.M., the resident sat at beside in a wheelchair, bedside table in front of resident, and a urinal holding 300 milliliters (ml) urine sat on table next to the resident's breakfast plate;
- On 12/1/21 at 9:05 A.M., the resident sat at beside in a wheelchair, bedside table in front of resident, uneaten breakfast meal, and a urinal holding 100 ml urine sat on table next to the resident's breakfast plate;
- On 12/2/21 at 9:35 A.M., the resident sat at beside in a wheelchair, bedside table in front of resident with dried liquid and food crumbs on it, and a urinal sat on table;
- On 12/7/21 at 9:30 A.M., the resident sat at beside in a wheelchair, bedside table in front of resident with dried liquid and food on it, and a urinal sat on table.
During an interview on 11/30/21 at 8:37 A.M., the resident said he/she wants the urinal to be where he/she can reach it and there isn't anywhere else to set it.
4. During an interview on 12/9/21 at 11:57 A.M., the Director of Operations and Administrator said they would expect all reasonable accommodations for residents to be made. They would expect:
- A resident to be oriented to their food presentation if they need to be;
- A resident to be assisted with moving out of the facility if they choose to;
- A urinal to be placed on a separate piece of furniture within a resident's reach so that it is not on the same table the resident eats their meals from, or for it to be care planned that the resident wants the urinal to be on the bedside table. The urinal should be empty during meals and the bedside table kept clean.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to create an environment that was respectful of the right...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant by providing a meal menu and schedule based on staff preference and not resident preference for one resident (Resident #12) out of 20 sampled residents, by failing to honor one sampled resident's (Resident #76's) preference for routine showers, and by not honoring one additional resident's (Resident #57) right to move from the facility. The facility's census was 81.
1. Record review of the facility's policy titled, Resident Rights Policy, dated 12/1/19, showed:
- It is the policy of this facility to provide quality healthcare through communication, respect, and sensitivity between the residents and those who provide them care. Our facility strives to promote the exercise of right for each resident, even if he or she is determined to be incompetent, should be able to assert these rights based on his or her degree of capability;
- Residents are able to make choices about his or her own life subject to the facility's rules, as long as those rules do not violate a regulatory requirement;
- Residents should participate in planning their care, which includes daily schedules.
2. Record review of the facility's policy titled, Showers/Bathing Policy, dated 12/1/16, showed:
- Showers/baths will be offered at a frequency of at least two times per week, unless otherwise requested by responsible party or resident;
- If a resident has a specific preference related to bathing/showering this will be identified on the resident's comprehensive care plan and care card.
3. Record review of Resident #12's medical record showed:
- admission date of 2/23/21;
- Diagnoses include pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
Record review of the resident's admission Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 3/6/21, showed:
- The brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 15 out of 15 which indicated the resident to be cognitively intact;
- Section H, for activities and preferences, to have all areas marked very important or somewhat important to the resident.
Record review of the Physician's Order Sheet (POS), dated 12/1/21, showed an order, dated 7/15/21, for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) three times a week.
Record review of the resident's comprehensive care plan, last updated 9/29/21, showed Resident #12 is dependent on staff for meeting his/her emotional, intellectual, physical, and social needs.
During an interview on 11/30/21 at 8:45 A.M., the resident said he/she likes to stick to a routine and have breakfast by 7:00 A.M. Resident #12 said he/she needs to eat by 7:00 A.M. on days he/she has dialysis, but would like to eat at that time every day. Resident #12 said staff get his/her breakfast before dialysis, but don't always give it to him/her that early on the days he/she does not have dialysis. Dietary Aide N will fry eggs for him/her on the days he/she is here, but no other staff will do that for him/her. Additionally, the resident would like to play bingo in the dining room but the facility will not provide a portable oxygen tank for him/her to use during the activity, so he/she does not go.
The facility did not meet the individual needs for the resident by providing breakfast at a time of his/her choice, nor with providing a portable oxygen tank to allow the resident to attend activities.
4. Record review of Resident #76's medical record showed:
- admission date of 4/8/19;
- Diagnoses include venous insufficiency (difficulty with blood returning to the heart from the legs), depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic pain (pain that is ongoing and usually lasts longer than six months);
- The quarterly MDS, dated [DATE], showed the BIMS score to be 10 out of 15 indicated the resident to be moderately cognitively impaired.
- The Comprehensive Care Plan, last updated 7/13/21, showed the resident required assistance with all ADLs.
Observation on 12/1/21 at 9:05 A.M. showed the resident to be unshaven.
During an interview on 12/1/21 9:05 A.M., the resident said he/she has not had a shower in over a week. He/she would like to have a shower and be shaved at least one time a week.
Record review of shower sheets provided by facility for 10/1/21 through 12/2/21 showed showers completed on 10/19/21, 10/20/21, 11/10/21, and 11/23/21. Total of four showers in nine weeks. The facility did not provide dates the resident had been shaved.
The facility did not honor the resident's wishes to be showered at least one time a week.
5. Record review of Resident #57's medical record showed:
- admission date of 2/14/19;
- A guardianship document, dated 9/13/21, to show the resident's sister to be the responsible party (RP);
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain;
- The quarterly MDS, dated [DATE], showed the BIMS score to be 14 out of 15, which indicated the resident to be cognitively intact.
- The comprehensive care plan, last updated 10/21/21 showed Resident #57 had indicated he/she chose to stay at the facility for now, but hoped to move to another facility in the future. Staff were to ask Resident #57 upon his/her annual assessment if he/she wanted to pursue moving and help as appropriate.
During interviews:
- On 11/29/21 at 1:10 P.M., Resident #57 said he/she did not like living at the facility and he/she wanted to move;
- On 12/1/21 at 9:15 A.M., the resident said he/she wanted to move and had told the Social Worker at the facility many times, but no one will help. The resident said the SW never follows up with the resident and is never available.
During an interview on 12/01/21 at 7:47 P.M., the RP said he/she has been doing all he/she knows to do to get the resident moved but no one will call back to discuss anything.
The facility did not honor the resident's and RP's requests to assist with moving the resident to another facility.
6. During an interview on 12/9/21 at 11:57 A.M., the Director of Operations and Administrator said they would expect a resident to receive a shower at a minimum twice a week and more often if they desire. The charge nurse on each shift is responsible to assure documentation of showers. They would expect an oxygen tank to be provided to a resident if they need one to enable them to attend activities, and they would expect assistance to move to another facility to be provided in a timely manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of a resident's advance directive (a written st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of a resident's advance directive (a written statement of a person's wishes regarding medical treatment) regarding code status (indicates if a person wants cardiopulmonary resuscitation (CPR: emergency life saving procedure performed when the heart stops beating) if the heart or breathing stops) for one resident (Resident #71) out of 20 sampled residents. The facility's census was 81.
Record review of the facility's undated Advanced Directive policy, showed:
- At the time of a resident's admission into the facility, it must be determined if a resident has existing advanced directives or wishes to establish advanced directives;
- The facility Admissions Coordinator and/or a Social Service Worker (SSW) will supply the resident and/or their representative with a copy of the facility's Advanced Directive
policy, as well as, educational materials and explanation of the resident's rights regarding formulating an advanced directive;
- If the resident has existing advance directives, the Admissions Coordinator and/or the SSW will document in the medical record what documentation was provided by the resident and/or their representative;
- The staff is to offer and assist the resident and/or representative in the completion of
the paperwork related to identifying the primary decision-maker, identifying situations where healthcare decision-making is needed, including life sustaining treatments, and communication of the resident's and/or the resident representative's choices to the interdisciplinary team.
Record review of Resident #71's medical record showed:
- An admission date of [DATE];
- Diagnoses of constipation (a condition with a difficulty of emptying the bowels), anemia (a condition of a deficiency of red blood cells or hemoglobin in the blood), dementia (a brain disease which may cause a decrease in thinking ability) without behavioral disturbance, and major depressive disorder (a mental disorder characterized by a persistently depressed mood);
- Resided on the secure memory care unit (MCU)
- No documentation of the resident's code status on his/her [DATE] Physician's Order Sheet (POS);
- No documentation of the resident's code status on his/her face sheet;
- Full code (all resuscitation procedures will be provided to keep them alive) addressed on his/her care plan.
Record review of the resident's CPR Order form, dated [DATE], showed:
- The resident/responsible party's choice for CPR or Do Not Resuscitate (DNR: no code, allow a natural death) not documented;
- The resident/responsible party signed the form on [DATE] but did not indicate whether CPR or DNR;
- The physician signed the form on [DATE] but did not indicate whether CPR or DNR;
- The facility did not obtain an order for the resident/responsible party's choice of CPR or DNR status.
During an interview on [DATE] at 2:16 P.M., Registered Nurse (RN) F said he/she is unsure what facility staff is responsible to check the residents' code statuses. The nurses should probably check that.
During an interview on [DATE] at 11:57 A.M., the Director of Operations said the social service designee (SSD) is responsible to ensure a resident's code status is accurate and complete. He/she would expect the SSD to check the completeness and accuracy of a resident's code status at least quarterly with their care plan meeting or as needed. The code status should be documented and updated on the care plan.
During a phone interview on [DATE] at 8:50 A.M., Restorative Aide (RA) O said the only way the staff know the code status of the residents that reside on the secure MCU is to look at the residents' hard charts to see their code status. Unfortunately, the residents' hard charts are kept at the secure 200 Hall nurses' station and the MCU staff have to leave the secured unit and go to the 200 Hall secured unit to look up a specific resident's code status in case of an emergency such as a code situation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP) of a change in condition and/or s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP) of a change in condition and/or status for two residents (Resident #33 and #36) out of 20 sampled residents and one resident (Resident #57) outside the sample. The facility's census was 81.
1. Record review of the facility's policy titled, Change in Resident's Condition or Status, dated 10/1/17, showed:
- Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status;
- Unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's family or representative when there is a significant change in the resident's physical, mental, or psychosocial status, and/or it is necessary to transfer the resident to a hospital/treatment center.
2. Record review of Resident #33's medical record showed:
- An original admission date 4/22/19 with re-admission date of 11/12/21;
- Diagnoses included chronic pain, major depressive disorder (long-term loss of pleasure or interest in life), Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), transient cerebral ischemic attack (TIA: a neurologic deficit that produces stroke symptoms that resolve within 24 hours), atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries causing obstruction of blood flow), and mood disorder (a condition which causes a person's emotional state to be distorted and interferes with the ability to function).
Record review of the resident's progress notes showed:
- On 9/26/21 at 3:00 P.M., resident on his/her back on the floor between the bed and wall. The resident stated he/she was putting soda in the refrigerator. Aide then moved the refrigerator to the other side of the bed;
- On 9/29/21 at 9:45 A.M., resident yelling from room at 7:00 A.M., found laying on stomach on floor in room in front of the door, stated he/she was trying to get to the bathroom and slipped. No visible injuries noted, no complaints of pain or discomfort, vital signs and neuros within normal limits, physician notified;
- No documentation staff notified RP of falls on 9/26/21 or 9/29/21.
3. Record review of Resident #36's medical record showed:
- Original admission date of 12/23/19 with re-admission date of 3/24/21,
- Diagnoses of dementia (disorder marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) with behavioral disturbance, major depressive disorder (long-term loss of pleasure or interest in life), chronic pain (pain that is ongoing and usually lasts longer than six months), hypertension (high blood pressure), and Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar).
Record review of the resident's progress notes showed:
- On 10/18/21 at 12:00 P.M. the resident with a wound approximately six centimeter (cm) by two cm red excoriation to his/her left buttock and approximately three cm by two cm. Nurse Practitioner notified;
- No documentation of Resident's RP notified of change in condition.
4. Record review of Resident #57's medical record showed:
- admission date of 2/14/19;
- A guardianship document, dated 9/13/21, indicating a new RP;
- Diagnoses include multiple sclerosis (MS: a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain;
Record review of the resident's Physician's Order Sheet (POS), dated 12/2/21, showed an order for Ivermectin (a medication used to treat infections caused by roundworms, threadworms, and other parasites) tablet three milligrams (mg), give five tablets by mouth one time every day for seven days for prevention treatment of scabies (an itchy skin condition caused by a tiny burrowing mite), take five tablets now and then again in seven days on 10/25/21.
Record review of the resident's nurse progress notes showed no documentation of RP notification of the change in medical condition related to the diagnosis of scabies.
During an interview on 11/30/21 at 10:09 A.M., the Social Worker (SW) said:
- Resident #57 has a guardian;
- The guardian's phone number is somewhere in her email;
- The guardian will add it to the resident's chart today;
- It should have already been done.
During a telephone interview on 12/01/21 at 7:47 P.M., the RP said he/she has been trying for months to communicate with the facility about the resident's care and condition. They never call the RP about anything. The RP would absolutely expect a phone call if there are any changes in the resident's condition.
Record review of the resident's nurse progress note, dated 12/1/21 at 8:10 P.M., showed Resident #57 transferred to a hospital on [DATE]. The record did not contain documentation that the RP was notified.
During a telephone interview on 12/2/21 at 7:46 A.M., the RP said the resident had been sent to the hospital last evening (12/1/21). The hospital called him/her for approval for some tests related to blood work results from tests ordered 11/30/21 at the facility. The resident was admitted on [DATE] following the results of further testing. The facility did not notify the RP of the testing, results or transfer.
5. During an interview on 12/9/21 at 11:57 A.M., the Director of Operations said she would expect the RP to be notified of a change in condition, status or hospitalization of a resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure discharge/transfer documentation included reasons for the di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure discharge/transfer documentation included reasons for the discharge/transfer, the discharge plan, and notification of the resident's responsible party for six residents (Resident #7, #12, #31, #49, #78 and #29) who were discharged to the hospital, out of six sampled residents and one resident (Resident #57) outside of the sample. The facility's census was 81.
1. Record review of the facility's policy titled, Notice of Transfer or Discharge of Nursing Home Resident, dated 4/2019, showed:
- Residents/Residents' Legal Representatives shall receive written notification if a resident is temporarily discharged /transferred to the hospital due to an urgent medical need;
- If a resident has had a change in condition, whether medical or psychological, requiring a hospital leave to address the urgent need, the charge nurse will complete a Notice of Transfer or Discharge of Nursing Home resident form;
- One copy of the completed form will be sent with the resident at the time of hospital transfer;
- One copy of the completed form will be given to the Social Services Director;
- One copy of the form will be given to the Admissions Coordinator;
- One copy of the form will remain in the resident's medical record;
- The Social Service Director will mail a copy of the completed form to the resident's legal representative, if applicable;
- The Admissions Coordinator will retain a copy of the form and notify the Ombudsman (statewide network of individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights are preserved and respected) of all discharges, including temporary discharges, on a monthly basis.
2. Record review of Resident #7's Physician's Order Sheet (POS), dated 12/1/21, showed:
- A re-admission date of 11/20/21;
- Diagnoses included generalized anxiety disorder, Crohn's disease (chronic inflammatory bowel disease that affects the lining of the digestive tract), colostomy (a surgical opening into the intestines for bowel elimination), insomnia (difficulty sleeping), major depressive disorder, bipolar disorder (a mental disorder with periods of elevated moods and depression) and paranoid schizophrenia (a long-term mental disorder that affects a person's ability to think, feel or behave clearly).
Record review of Resident #7's nurse's notes showed on 10/29/21 at 1:30 P.M., the resident sent to emergency room (ER) for evaluation.
Review of the resident's medical record, showed no documentation of the reason for hospital transfer, the hospital transfer notice, or the bed hold policy.
Record review of Resident #7's nurse's notes showed on 11/19/21 at 5:33 P.M., resident sent to the ER for evaluation of ileostomy (a surgical operation in which a piece of the intestines is diverted to an artificial opening in the abdominal wall).
Review of the resident's medical record, showed no documentation of the hospital transfer notice.
3. Record review of Resident #12's medical record showed:
- An admission date of 2/23/21;
- Diagnoses include kidney failure, chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure.
Record review of Resident #12's progress notes showed:
- The resident transferred to the hospital on 4/15/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on 5/27/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on 7/30/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on [DATE], and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on [DATE], and re-admitted to the facility on [DATE].
Review of the resident's medical record, showed no documentation of a hospital transfer notice provided to the resident and/or the resident's representative.
4. Record review of Resident #31's POS, dated 12/1/21, showed:
- An admission date of 9/13/21;
- Diagnoses included insomnia, anxiety disorder, COPD, ataxia (unsteady gait), hypertension (high blood pressure), seizures, psychosis (a mental disorder with a severe loss of contact with reality) and schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions).
Record review of the resident's nurse's notes, dated 9/9/21, showed the resident yelling and cussing at staff and other residents. Resident yelled at another resident's service dog and attempted to punch the dog. Order received to send to hospital.
Review of the resident's medical record showed no documentation of the hospital transfer notice.
5. Record review of Resident #49's medical record showed:
- An admission date of 10/4/17;
- Diagnoses of dementia with behavioral disturbance (a brain disease which may cause a decrease in thinking ability), cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), urinary tract infection (UTI), and schizophrenia.
Record review of Resident #49's progress notes showed the resident transferred to the hospital on [DATE], and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no documentation of a hospital transfer notice provided to the resident and/or the resident's representative.
6. Record review of Resident #57's medical record showed:
- An admission date of 2/14/19;
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain.
Record review of Resident #57's progress notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no documentation of a hospital transfer notice provided to the resident and/or the resident's representative.
7. Record review of Resident #78's POS, dated 12/1/21, showed:
- An admission date of 9/1/21;
- Diagnoses included Alzheimer's disease (progressive mental deterioration), hypertension, heart failure, and psychosis.
Record review of Resident #78's nurse's notes, dated 10/20/21, showed the resident on his/her right side on the floor, hit his/her head hard on the floor and complaining of neck, head and back pain. Sending to the ER;
Review of the resident's medical record showed no documentation of the hospital transfer notice.
8. Record review of Resident #29's medical record showed:
- An original admission date of 9/26/20;
- discharged to the hospital 10/25/21 and re-admitted to the facility on [DATE];
- Diagnoses included anxiety disorder and hypertension.
Record review of the resident's nurse's note/progress note, dated 10/25/21, showed the resident called 911 (emergency personnel) and told informed the Emergency Medical Service (EMS), he/she was suicidal with a plan and was in pain. EMS arrived and transported the resident to hospital for an evaluation and treatment.
Review of the resident's medical record showed no documentation the resident and/or the resident's representative was provided with the discharge/transfer notice.
9. During an interview on 12/01/21 P.M., Social Services said the nurses are supposed to fill out and send the transfer/discharge notice with the resident to the hospital. The notice is supposed to be provided to the family or responsible party. It appears this was not being done.
During an interview on 12/8/21 at 2:16 P.M., Registered Nurse (RN) F said the charge nurse doesn't complete a transfer form that is given to the resident and/or the resident's representative when a resident is transferred to the hospital. He/she is unsure who is responsible for that. The charge nurses fill out the nursing transfer form which is required to go to the hospital with the resident's pertinent health information documented on it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document preparation and orientation for transfer to the hospital f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document preparation and orientation for transfer to the hospital for four residents (Residents #7, #12, #31, and #78) out of six sampled residents who were discharged to the hospital and one resident (Resident #57) outside the sample. The facility's census was 81.
1. The facility did not provide a policy for preparation and orientation for transfer or discharge.
2. Record review of Resident #7's Physician's Order Sheet (POS), dated 12/1/21, showed:
- A re-admission date of 11/20/21;
- Diagnoses included generalized anxiety disorder, Crohn's disease (chronic inflammatory bowel disease that affects the lining of the digestive tract), colostomy (a surgical opening into the intestines for bowel elimination), insomnia (difficulty sleeping), major depressive disorder, bipolar disorder (a mental disorder with periods of elevated moods and depression) and paranoid schizophrenia (a long-term mental disorder that affects a person's ability to think, feel or behave clearly).
Record review of Resident #7's nurse's notes showed the resident transferred to the hospital on:
- 10/29/21 and re-admitted to the facility on [DATE];
- 11/19/21 and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no documentation that staff prepared and oriented the resident prior to transfer to the hospital.
3. Record review of Resident #12's medical record showed:
- An admission date of 2/23/21;
- Diagnoses include kidney failure, chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure.
- The resident transferred to the hospital on 4/15/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on 5/27/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on 7/30/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on [DATE], and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on [DATE], and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no documentation that staff prepared and oriented the resident prior to transfer to the hospital.
4. Record review of Resident #31's Physician's Order Sheet, dated 12/01/21, showed:
- An admission date of 9/13/21;
- Diagnoses included insomnia, anxiety disorder, COPD, ataxia (unsteady gait), hypertension (high blood pressure), seizures, psychosis (a mental disorder with a severe loss of contact with reality), and schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions).
Record review of Resident #31's nurse's notes showed the resident transferred to the hospital on 9/09/21. Staff did not document when the resident was re-admitted .
Review of the resident's medical record showed no documentation that staff prepared and oriented the resident prior to transfer to the hospital.
5. Record review of Resident #57's medical record showed:
- An admission date of 2/14/19;
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain.
Record review of Resident #57's progress notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no documentation that staff prepared and oriented the resident prior to transfer to the hospital.
6. Record review of Resident #78's Physician's Order Sheet, dated 12/01/21, showed:
- An admission date of 9/01/21;
- Diagnoses included Alzheimer's disease (progressive mental deterioration), hypertension, heart failure, and psychosis.
Record review of Resident #78's nurse's notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility the same day.
Review of the resident's medical record showed no documentation that staff prepared and oriented the resident prior to transfer to the hospital.
7. During an interview on 12/2/21 at 1:57 P.M., the Quality Assurance Nurse said the residents are prepared or should be prepared and oriented for transfer, but the nurses do not always document it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for six residents (Resident #7, #12, #31, #49, #78 and #29) out of six sampled residents and one resident (Resident #57) outside the sample. The facility's census was 81.
1. Record review of the facility's undated policy titled, Bed Hold Policy, showed:
- It is the policy of the facility to notify the Resident/Responsible Party of the bed hold policy;
- This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave.
2. Record review of Resident #7's Physician's Order Sheet, dated 12/01/21, showed:
- A re-admission date of 11/20/21;
- Diagnoses included generalized anxiety disorder, Crohn's disease (chronic inflammatory bowel disease that affects the lining of the digestive tract), colostomy (a surgical opening into the intestines for bowel elimination), insomnia (difficulty sleeping), major depressive disorder (long-term loss of pleasure or interest in life), bipolar disorder (a mental disorder with periods of elevated moods and depression), and paranoid schizophrenia (a long-term mental disorder that affects a person's ability to think, feel or behave clearly).
Record review of Resident #7's nurse's notes showed:
- The resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE];
- The resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no written documentation that the notification for bed hold was provided to the resident and/or his/her responsible party.
3. Record review of Resident #12's medical record showed:
- An admission date of 2/23/21;
- Diagnoses include kidney failure, chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure.
Record review of Resident #12's progress notes showed:
- The resident transferred to the hospital on 4/15/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on 5/27/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on 7/30/21, and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on [DATE], and re-admitted to the facility on [DATE].
- The resident transferred to the hospital on [DATE], and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no written documentation that the notification for bed hold was provided to the resident and/or his/her responsible party for any of the above transfers to the hospital.
4. Record review of Resident #31's Physician's Order Sheet, dated 12/01/21, showed:
- An admission date 9/13/21;
- Diagnoses included insomnia, anxiety disorder, COPD, ataxia (unsteady gait), hypertension (high blood pressure), seizures, psychosis (a mental disorder with a severe loss of contact with reality), and schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions).
Record review of Resident #31's nurse's notes showed the resident transferred to the hospital on 9/9/21 and no documentation of when the resident was re-admitted to the facility.
Review of the resident's medical record showed no written documentation that the notification for bed hold was provided to the resident and/or his/her responsible party.
5. Record review of Resident #49's medical record showed:
- An admission date of 10/4/17;
- Diagnoses of dementia with behavioral disturbance (a brain disease which may cause a decrease in thinking ability), cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), urinary tract infection (UTI), and schizophrenia.
Record review of Resident #49's progress notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no written documentation that the notification for bed hold was provided to the resident and/or his/her responsible party.
6. Record review of Resident #78's Physician's Order Sheet, dated 12/01/21, showed:
- An admission date of 9/01/21;
-Diagnoses included Alzheimer's disease (progressive mental deterioration), hypertension, heart failure, and psychosis.
Record review of Resident #78's nurse's notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility the same day.
Review of the resident's medical record showed no written documentation that the notification for bed hold was provided to the resident and/or his/her responsible party.
7. Record review of Resident #29's medical record showed:
- An original admission date of 9/26/20;
- discharged to the hospital 10/25/21 and re-admitted to the facility 11/8/21;
- Diagnoses included depression (a serious medical illness that negatively affects how you feel, the way you think and how you act).
Record review of Resident #29's nurse's note/progress note, dated 10/25/21, showed the resident called 911 (emergency personnel) and informed the Emergency Medical Service (EMS) he/she was suicidal and with a plan and was in pain. EMS arrived and transported the resident to hospital for an evaluation and treatment.
Review of the resident's medical record showed no written documentation that the notification for bed hold was provided to the resident and/or his/her responsible party.
8. Record review of Resident #57's medical record showed:
- An admission date of 2/14/19;
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain.
Record review of Resident #57's progress notes showed the resident transferred to the hospital on [DATE] and re-admitted to the facility on [DATE].
Review of the resident's medical record showed no written documentation that the notification for bed hold was provided to the resident and/or his/her responsible party.
9. During an interview on 12/2/21 at 1:57 P.M., the Quality Assurance (QA) Nurse said the residents should receive the bed hold policy when transferred. The nurses are responsible for this but may not always do it.
During an interview on 12/08/21 at 2:16 P.M., Registered Nurse (RN) F said the charge nurse doesn't complete a bedhold policy when a resident is transferred to the hospital. He/she is unsure who is responsible for that. The charge nurses fill out the nursing transfer form that is required to go to the hospital with the resident's pertinent health information documented on it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a significant change assessment as required for two residents who were admitted to hospice care (Residents #52 and #334) out of 20...
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Based on interview and record review, the facility failed to complete a significant change assessment as required for two residents who were admitted to hospice care (Residents #52 and #334) out of 20 sampled residents. The facility's census was 81.
1. The facility did not provide a policy on completing Minimum Data Set (MDS: a federally mandated assessment, required to be completed by the facility) assessments.
2. Review of Resident #52's medical record showed:
- An admission date of 1/31/19;
- Diagnoses include dementia (disorder marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning), and chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs);
- The resident admitted to hospice (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) on 8/24/21.
The facility did not complete a significant change MDS after the resident was placed on hospice as required.
3. Review of Resident #334's medical record showed:
- An admission date of 4/26/19;
- Diagnoses include bipolar disorder (mental disorder that causes unusual shifts in mood), Alzheimer's disease (progressive mental deterioration), diabetes mellitus (condition that affects the way the body processes blood sugar), major depressive disorder-recurrent (long-term loss of pleasure or interest in life), and chronic kidney disease (a gradual loss of kidney function).
- The resident admitted to hospice on 7/15/21.
The facility did not complete a significant change MDS after the resident was placed on hospice as required.
4. During an interview on 12/7/21 at 3:27 P.M., the Director of Operations said their MDS Coordinator had just resigned and now they have someone else doing them, but only two days a week. They are in transition so they do not have a MDS Coordinator at this time. The previous MDS Coordinator had been ill and was working from home. Therefore, the MDSs haven't been completed and/or transmitted in the appropriate timeframe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to electronically transmit a Minimum Data Set (MDS: a federally mandat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to electronically transmit a Minimum Data Set (MDS: a federally mandated assessment instrument completed by the facility staff) in a timely manner and in accordance with guidelines for one resident (Resident #12) out of 20 sampled residents and two residents (Residents #56 and #72) outside the sample. The facility's census was 81.
1. Record review of Resident #12's MDS records showed:
- Quarterly MDS dated [DATE], completed but not transmitted;
- The facility did not transmit the MDS within 14 days of the completion date.
2. Record review of Resident #56's MDS records showed:
- Quarterly MDS dated [DATE], completed but not transmitted;
- The facility did not transmit the MDS within 14 days of the completion date.
3. Record review of Resident #72's MDS records showed:
- Quarterly MDS dated [DATE], completed but not transmitted;
- The facility did not transmit the MDS within 14 days of the completion date
4. During an interview on 12/7/21 at 3:27 P.M., the Infection Preventionist and the Director of Operations said the previous MDS Coordinator gave his/her resignation and the facility has another nurse working on MDSs two days a week. The facility is currently in transition and does not have an MDS Coordinator and the MDSs haven't been completed and/or transmitted in the appropriate timeframe.
During an interview on 12/9/21 at 11:57 A.M., the Director of Nursing and the Administrator said the facility would expect MDS assessments to be transmitted on time.
The facility did not provide a policy for MDS transmission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure two sampled residents (Residents# 42 and 52) with a mental disorder had a Preadmission Screening for individuals with a mental disor...
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Based on interview and record review, the facility failed to ensure two sampled residents (Residents# 42 and 52) with a mental disorder had a Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability (Preadmission Screening and Resident Review- PASRR) completed prior to admission, out of 20 sampled residents . The facility's census was 81.
1. Record review of Resident #42's medical record showed:
- An original admission date of 6/7/21 with re-admission date of 11/12/21;
- Diagnoses of bipolar disorder (a mental disorder that causes unusual shifts in mood), generalized anxiety disorder (persistent worry and fear about everyday situations), and major depressive disorder (long-term loss of pleasure or interest in life);
- No Preadmission Screening completed.
2. Record review of Resident #52's medical record showed:
- An admission date of 1/31/19;
- Diagnoses include dementia (disorder marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning);
- The quarterly Minimum Data Set (MDS: a federally mandated assessment, required to be completed by the facility), dated 5/5/21, showed the brief interview for mental status (BIMS: a tests used to get a quick snapshot of how well the resident is functioning cognitively), score to be 10 out of 15 which indicated as the resident to be moderately cognitively impaired;
- No Preadmission Screening completed.
3. During an interview on 12/9/21 at 11:57 A.M., the Administrator, Director of Nursing, and Director of Operations said they would expect there to be a Preadmission Screening for residents who require one. They were unable to locate a screening for residents #42 and #52.
4. The facility did not provide a policy for PASRR Screening.
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 failed to implement a baseline care plan (an initial plan for delivery of car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a baseline care plan (an initial plan for delivery of care and services) with tailored specific interventions within 48 hours of admission as required by regulation and within 24 hours in accordance with the facility's policy for two residents (Resident #12 and #71) out of 20 sampled residents. The facility's census was 81.
1. Record review of the facility's policy titled, The Estates, regarding care plans, dated 7/20, showed:
- A care plan shall be used in developing residents' daily care routines and will be available to staff for review to ensure the best person-centered care can be provided to our residents;
- An interim Care plan will be completed by the nursing department within 24 hours of admission;
- The care plan will be accessible to staff for review at any time.
2. Record review of Resident #12's medical record showed:
- An admission date of 2/23/21;
- The resident is his/her own responsible party (RP);
- The admission Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 3/6/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 15 out of 15 which indicated the resident to be cognitively intact.
- The interim (baseline) care plan dated 4/23/21 (two months after admission).
During an interview on 11/30/21 at 8:45 A.M., the resident said staff has never talked to him/her about care/goals nor included the resident in the development of a care plan.
3. Record review of Resident #71's Physician Order Sheet (POS), dated December 2021, showed:
- An admission date of 1/12/21;
- Diagnoses of constipation (a condition with a difficulty of emptying the bowels), anemia (a condition of a deficiency of red blood cells or hemoglobin in the blood), dementia (a brain disease which may cause a decrease in thinking ability) without behavioral disturbance, and major depressive disorder (a mental disorder characterized by a persistently depressed mood).
Record review of the resident's admission MDS, dated [DATE], showed:
- Severely impaired cognitive status;
- Inattention and disorganized thinking daily;
- Minimal assistance of one staff with dressing and personal hygiene;
- Moderate assistance of one staff with bathing;
- A current tobacco user;
- Received an antipsychotic (a major tranquilizer) medication.
Record review of the resident's medical record showed:
- No baseline care plan completed.
4. During an interview on 12/8/21 at 2:16 P.M., Registered Nurse (RN) F said baseline care plans are to be completed by the admitting nurse.
5. During an interview on 12/9/21 at 11:57 A.M., the Administrator said the admitting nurse is responsible for completing a resident's baseline care plan and she would expect it to be completed within 48 hours of admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to clarify physician's orders for antibiotic use and change a suprapub...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to clarify physician's orders for antibiotic use and change a suprapubic (SP: a suprapubic catheter is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) catheter for one resident (Resident #4); the facility failed to follow physician's orders for suture removal for one resident (Resident #33); the facility failed to consistently administer pain medication and monitor oxygen saturation for one resident (Resident #12); the facility failed to administer medication for type two diabetes mellitus (DM: condition that affects the way the body processes blood sugar) for one resident (Resident #76); and the facility failed to obtain physician orders for wound care for one resident (#334), out of the 20 sampled residents. The facility failed to consistently administer an antipsychotic medication for two residents (Residents #40 and #56) outside the sample. The facility's census was 81.
1. The facility did not provide a policy for medication administration or for re-ordering medications.
2. Record review of the facility's policy titled, Physician/Medication Order Policy, dated 12/1/18, showed:
- The facility shall use uniform guidelines for the ordering of medications and physician orders;
- Documentation of medication orders: clarify the order.
3. Record review of Resident #4's medical record showed:
- An admission date of 9/17/20;
- Diagnoses include benign prostatic hyperplasia (BPH: enlargement of the prostate causing difficulty in urination) with lower urinary tract symptoms, hypokalemia (decreased blood level of potassium), congestive heart failure (CHF: an inability of the heart to pump sufficient blood flow to meet the body's needs), retention of urine, and urinary tract infection (UTI);
- Physician's Order Sheet (POS), dated 12/1/21, with an order, dated 10/29/21 with a start date of 10/30/21, for Augmentin (an antibiotic medication) 875-125 milligram (mg) twice daily related to UTI with no end date;
- Medication Administration Record (MAR), dated October 2021 through December 2021, the resident received Augmentin 875-125 mg twice daily on 10/30/21, 10/31/21, 11/1/21 through 11/30/21, 12/1/21 through 12/7/21, and once on 12/8/21, total of 59 extra doses;
- POS, dated 12/1/21, with an order dated 9/23/21 with a start date of 10/22/21, to change SP tube monthly on the 22nd of each month related to retention of urine;
- Comprehensive care plan, last revised 10/19/21, to change SP catheter as ordered;
- Treatment Administration Record (TAR), dated 10/1/21 through 10/31/21, the resident's catheter was not changed in October.
During a telephone interview on 12/14/21 at 4:19 P.M., the Administrator said she would expect staff to clarify physician's orders for an antibiotic without an end date.
During an interview via email on 12/15/21 at 4:31 P.M., the Administrator said the Director of Nursing (DON) followed up with the resident's physician. The order for Augmentin was for 10 days. An order was received to discontinue the medication.
4. Record review of Resident #12's medical record showed:
- admission date of 2/23/21;
- Diagnoses include pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
- The quarterly Minimum Data Set (MDS: a federally mandated assessment, required to be completed by the facility), dated 6/6/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 which indicated the resident to be cognitively intact.
Record review of the resident's POS, dated 12/1/21, showed:
- An order, dated 4/28/21, for oxycodone HCl (a medication used to treat severe pain) 20 mg every six hours for pain;
- An order, dated 4/22/21, to take oxygen saturation every shift;
- No order for oxygen.
Record review of the resident's MAR showed:
- For the dates of 10/1/21 - 10/31/21, showed oxycodone 20 mg not administered 17 out of 124 opportunities without a reason documented;
- For the dates of 11/1/21 - 11/30/21, showed oxycodone 20 mg not administered 18 out of 120 opportunities without a reason documented;
- For the dates of 12/1/21 - 12/1/21, showed oxycodone 20 mg not administered 2 out of 4 opportunities without a reason documented.
During an interview on 11/30/21 at 8:45 A.M., Resident #12 said he/she needs more pain medication. Resident #12 said he/she agreed to palliative care, (PC: an interdisciplinary medical care giving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex illnesses) to better control the pain. The resident said he/she has pain in all joints due to DM neuropathy (a disease of the nerves causing tingling, burning or loss of sensation). He/she has taken hydrocodone (pain medication) for years and the doctor has never increased his/her dose.
During an interview on 11/30/21 at 10:05 A.M., Resident #12 said his/her pain is not controlled and they (the facility staff) refuse to change or increase his/her pain medication. He/she agreed to palliative care so that they could get his/her pain under control but they haven't changed anything.
Record review of the comprehensive care plan, last updated 9/29/21 showed no care plan for oxygen.
Observation on 11/30/21 at 10:13 A.M., showed the resident lay in bed. A nasal cannula oxygen tubing lay on the floor beside the bed.
During an interview on 11/30/21 at 10:13 A.M., the resident said he/she uses oxygen sometimes. The resident said the facility does not change the tubing or fill the water bottle. He/she fills it with tap water.
Observation on 12/2/21 at 9:25 A.M., showed the resident wore the supplemental oxygen and the flowmeter set at three liters.
Observation on 12/7/21 at 9:40 A.M., showed the resident wore the supplemental oxygen and the flowmeter set at three liters.
Record review of the medication administration record (MAR):
- For the dates of 10/1/21 - 10/31/21 showed oxygen saturation documentation with 19 of 93 missed opportunities;
- For the dates of 11/1/21 - 11/30/21 showed oxygen saturation documentation with 25 of 90 missed opportunities.
5. Record review of Resident #33's medical record showed:
- An original admission date of 4/22/19 with a re-admission date of 11/12/21;
- Diagnoses include type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), transient cerebral ischemic attack (TIA: a neurologic deficit that produces stroke symptoms that resolve within 24 hours), atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries causing obstruction of blood flow), and mood disorder (a condition which causes a person's emotional state to be distorted and interferes with the ability to function);
Record review of Resident #33's Progress Notes showed:
- On 10/14/21, the resident returned to facility via ambulance. 12 sutures to laceration on left side of face, dressed with telfa and secured with coban. Resident currently alert and oriented to self only. Follow up with primary care physician for suture removal in 7-10 days (10/21/21- 10/24/21).
- On 11/3/21, alerted that resident still had sutures in his/her forehead. Called hospital and was told that sutures need to be removed. Nurse removed sutures from forehead (10 days late). Resident tolerated well. Area cleansed and left open to air. Will monitor.
6. Record review of Resident #40's medical record showed:
- admitted [DATE];
- Diagnoses include schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), anxiety disorder (persistent worry and fear about everyday situations), and major depressive disorder (long-term loss of pleasure or interest in life).
Record review of the resident's POS, dated 12/08/21, showed:
- Clozapine (Clozaril: to treat schizoaffective disorders) 100 mg, three tablets by mouth at bedtime for schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly);
- Clozaril 25 mg tablet by mouth one time a day for schizophrenia.
Record review of the resident's MAR, dated 11/1/21-11/30/21, showed:
- Clozapine 100 mg: Medication not administered 5 out of 30 opportunities due to medication not available;
- Clozapine 25 mg: Medication not administered 1 out of 30 opportunities due to medication not available.
7. Record review of Resident #56's medical record showed:
- admitted [DATE];
- Diagnoses include schizoaffective disorder, bipolar disorder (mental disorder that causes unusual shifts in mood), mild intellectual disabilities and histrionic personality disorder (mental health disorder that affects the way a person thinks, perceives and relates to others.
Record review of the resident's POS, dated 12/08/21, showed Clozapine Disintegrating Tablet (dissolves quickly) 100 mg by mouth one time a day for mood stabilizer.
Record review of the resident's MAR showed
- For the dates of 11/1/21-11/30/21, Clozapine 100 mg: Medication not administered 9 out of 30 opportunities due to medication not available;
- For the dates of 12/1/21-12/8/21, Clozapine 100 mg: Medication not administered 4 out of 8 opportunities due to medication not available.
8. Record review of Resident #76's medical record showed:
- admission date of 4/8/19;
- Diagnoses include venous insufficiency (difficulty with blood returning to the heart from the legs), depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic pain (pain that is ongoing and usually lasts longer than six months);
- The quarterly MDS, dated [DATE], showed the BIMS score to be 10 out of 15 indicating the resident to be moderately cognitively impaired.
Record review of the resident's medical record showed:
- The resident's POS, dated 12/1/21, an order, dated 8/14/19, for Ocuvite tablet with lutein (a dietary supplement available without a prescription, used to help protect eye health) for diagnosis of type two diabetes mellitus, one tablet two times daily;
- The resident's MAR, dated 11/1/21 - 11/30/21, an order for Occuvite with lutein. The medication not administered two of 60 opportunities due to medication not available.
During an interview on 12/08/21 at 1:50 P.M., the Director of Nursing (DON) said that she would expect for medications to be re-ordered when needed and for the pharmacy to deliver the medication in 24 hours. The physician should be notified if a resident is out of their medication and would miss any doses. The medication was not in t he building due to pharmacy awaiting the facility to fax laboratory results before they would send out the clozapine.
9. Record review of Resident #334's medical record showed:
- admission date of 4/26/19;
- Diagnoses include bipolar disorder, Alzheimer's disease (progressive mental deterioration), diabetes mellitus (condition that affects the way the body processes blood sugar), major depressive disorder-recurrent (long-term loss of pleasure or interest in life), and chronic kidney disease (a gradual loss of kidney function);
- The annual MDS, dated [DATE], showed the BIMS score to be not evaluated;
- Extensive assistance for mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Frequently incontinent of bowel and bladder.
The resident's December 2021 POS showed:
- An order, dated 10/18/21, triad hydrophillic sound dress paste, (a zinc oxide-based hydrophilic paste that absorbs moderate levels of wound exudate), apply to buttocks topically as needed for skin, apply after each incontinent episode, may keep at bedside;
- An order, dated 10/18/21, triad hydrophillic sound dress paste, apply to right buttock topically as needed for wound care, clean area, apply cream daily and as needed;
- An order, dated 10/18/21, triad hydrophillic sound dress paste, apply to right buttock topically for wound care, clean area, apply cream twice daily and as needed;
- No order for wound care to left shoulder.
Record review of the comprehensive care plan, last updated 8/27/21, showed no care plan for skin or wound care.
Observation on 12/7/21 at 2:45 P.M. showed there to be a two inch by two inch gauze covering secured on the resident's left shoulder.
During an interview on 12/7/21 at 2:45 P.M., LPN G said the resident has a wound to his/her left shoulder, really like a little blister.
Observation on 12/7/21 at 2:50 P.M., showed LPN G removed the dressing from the resident's shoulder; observation showed the wound to be an open blister about ½ inch oval in size.
Observation showed LPN G performed wound care to the resident's left shoulder, applied bactroban ointment (a prescription medicine used to treat skin infections) and applied and secured a gauze dressing.
The facility did not obtain a physician order for wound care to the resident's left shoulder.
10. During an interview on 12/08/21 at 1:50 P.M., the Director of Nursing (DON) said the medications were not administered due to the medications not being in the building. Pharmacy needed a copy of the most recent labs before they would send out the medication. The DON said that she would expect for medications to be re-ordered when needed and for the pharmacy to deliver the medication in 24 hours. The physician should be notified if a resident is out of their medication and would miss any doses.
11. During an interview on 12/09/21 at 11:57 A.M., the Administrator said she would expect the physician to be notified if a resident is not receiving their medications as per the physician's orders. She would expect pain medications to be given as ordered. The medications should be ordered and it is expected the pharmacy should deliver the medication in 24 hours. The Director of Operations said there should be orders for all treatments and orders should be followed as written.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide consistent resident care for activities of daily living (AD...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide consistent resident care for activities of daily living (ADLs) for five residents (Residents #36, #49, #71, #76, and #78) out of 20 sampled residents and four residents (Resident #46, #55, #57, and #180) outside the sample. The facility's census was 81.
Record review of the facility's policy titled, Showers/Bathing Policy, dated 12/1/2016, showed:
- It is our facility policy to encourage and offer assistance to our resident's to maintain proper hygiene and cleanliness of their person;
- Showers/Baths will be offered at a frequency of at least two times per week, unless otherwise requested by the responsible party or resident;
- If a resident has a specific preference related to bathing/showering this will be identified on the resident's comprehensive care plan and care card.
1. Record review of Resident #36's medical record showed:
- An admission date of 3/24/21;
- Diagnoses include unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with behavioral disturbance and Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) with unspecified complications;
- Moderate cognitive impairment;
- The Comprehensive Care Plan, last updated 7/19/21, showed the resident to be assisted with ADLs when needed.
During an interview on 12/1/21 at 9:45 A.M., Resident #36 said he/she is supposed to get a shower today. Resident #36 said he/she has been at the facility for 3-4 months and has yet to have a shower.
Record review of the resident's shower sheets for 10/1/21 through 12/2/21, showed:
- Shower received on 10/6/21;
- Shower received on 11/1/21, 26 days later;
- Shower received on 11/23/21, 22 days later;
- Per facility policy, a shower should be offered two times a week, which would be around 20 shower opportunities in a 60 day time period.
2. Record review of Resident #46's medical record showed:
- An admission date of 10/5/18;
- Diagnoses include heart failure (chronic condition in which the heart doesn't pump blood as well as it should), pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), diabetes mellitus, anxiety (a feeling of worry, nervousness, or unease), schizophrenia (a long-term mental disorder that affects a person's ability to think, feel or behave clearly), and suicidal ideations (when a person thinks about killing themselves);
- The Comprehensive Care Plan, last updated 10/21/21, showed the resident to be assisted with ADLs when needed;
- The quarterly Minimum Data Set (MDS: a federally mandated assessment, required to be completed by the facility), dated 6/26/21, showed the brief interview for mental status (BIMS: a tests used to get a quick snapshot of how well the resident is functioning cognitively), score to be 12 out of 15 which indicated as the resident to be moderately cognitively impaired;
- Totally dependent on one staff for transfers, personal hygiene and bathing.
Observation on 12/1/21 at 9:20 A.M. showed the resident to have unbrushed hair.
During an interview on 12/01/21 at 9:20 AM Resident #36 said he/she had not had a shower for 7 days. The staff are busy and had to skip him/her. The resident would like to have a shower two or three times a week but can't because they don't have enough people to help him/her.
The facility did not provide shower sheets for the resident.
3. Record review of Resident #49's annual MDS dated [DATE], showed:
- admission date of 10/4/17;
- Diagnoses of dementia with behavioral disturbance (a brain disease which may cause a decrease in thinking ability), cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), and schizophrenia;
- Bathing to be very important.
Record review of the resident's quarterly MDS, dated [DATE], showed:
- Moderately impaired cognitive status;
- Physical help with assist of one staff for bathing.
Record review of the resident's shower sheets for 10/1/21 through 12/2/21, showed:
- Shower received on 10/5/21;
- Shower received on 10/19/21, 14 days later;
- Shower received on 11/11/21, 23 days later;
- No shower documented after 11/11/21 and the resident hospitalized on [DATE];
- Per facility policy, a shower should be offered two times a week, which would be around 20 shower opportunities in a 60 day time period.
4. Record review of Resident #55's annual MDS, dated [DATE], showed:
- An admission date of 8/7/19;
- Diagnoses of DM, anxiety, depression, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), and bipolar disorder (a mental health condition that causes extreme mood swings);
- Bathing to be very important;
- Cognitively intact;
- Independent with bathing.
Record review of the resident's shower sheets for 10/1/21 through 12/2/21, showed:
- Shower received on 10/2/21;
- Shower received on 10/11/21, 9 days later;
- Shower received on 10/13/21;
- Shower received on 10/31/21; 18 days later;
- Shower received on 11/4/21;
- Shower received on 11/10/21, 6 days later;
- Shower received on 11/12/21;
- Shower received on 11/22/21, 10 days later;
- Shower received on 11/24/21;
- Shower received on 12/2/21, 8 days later;
- Per facility policy, a shower should be offered two times a week, which would be around 20 shower opportunities in a 60 day time period.
5. Record review of Resident #57's medical record showed:
- An admission date of 2/14/19;
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain;
- The Comprehensive Care Plan, last updated 10/21/21, showed the resident required assistance with brushing hair and washing face, set up supplies for brushing teeth.
Record review of the quarterly MDS, dated [DATE], showed:
- The BIMS score to be 14 out of 15 which indicated the resident to be cognitively intact:
- Extensive assistance for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Always incontinent of bowel and bladder.
Observations showed:
- On 11/29/21 at 1:10 P.M., the resident's teeth to be black, broken and food between his/her lips, gums and teeth;
- On 12/1/21 at 9:15 A.M., the resident's teeth to be black, broken and food between his/her lips, gums and teeth;
- On 12/8/21 at 1:55 PM., the resident's teeth to be black, broken and food between his/her lips, gums and teeth.
- On 12/9/21 at 2:00 PM., the resident's teeth to be black, broken and food between his/her lips, gums and teeth.
During an interview on 12/1/21 at 9:15 A.M., Resident #57 said staff do not take care of him/her.
During an interview on 12/1/21 at 7:47 P.M., the resident's Responsible Party said the resident used to have beautiful white teeth and a beautiful smile and now his/her teeth are in terrible condition.
During an interview on 12/9/21 at 1:55 P.M., the resident said no one has helped him/her brush his/her teeth since he/she was admitted over a year ago. The Administrator was present during the interview.
6. Record review of Resident #71's admission MDS, dated [DATE], showed:
- An admission date of 1/12/1721;
- Diagnosis of dementia without behavioral disturbance.
Record review of the resident's quarterly MDS, dated [DATE], showed:
- Severely impaired cognitive status;
- Physical help with assist of one staff for bathing.
Record review of the resident's shower sheets for 10/1/21 through 12/2/21, showed:
- Shower received on 10/7/21;
- Shower received on 10/21/21, 14 days later;
- Shower received on 11/15/21 with no documentation of a shower after this date, 17 days after last shower;
- Per facility policy, a shower should be offered two times a week, which would be around 20 shower opportunities in a 60 day time period.
7. Record review of Resident #76's medical record showed:
- An admission date of 4/8/19;
- Diagnoses include venous insufficiency (difficulty with blood returning to the heart from the legs), depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic pain (pain that is ongoing and usually lasts longer than six months);
- The Comprehensive Care Plan, last updated 7/13/21, showed the resident required assistance with all ADLs;
- The quarterly MDS dated [DATE], showed the BIMS score to be 10 out of 15 indicated the resident to be moderately cognitively impaired;
- Totally dependent on one staff for transfers, personal hygiene and bathing;.
Observation on 12/1/21 at 9:05 A.M. showed the resident to be unshaven.
During an interview on 12/1/21 9:05 A.M., the resident said he/she has not had a shower in over a week. He/she would like to have a shower and be shaved at least one time a week.
Record review of shower sheets provided by facility for 10/1/21 through 12/2/21 showed:
- Shower received on 10/19/21;
- Shower received on 10/20/21;
- Shower received on 11/10/21, 21 days later;
- Shower received on 11/23/2, 13 days later;
- A total of 4 showers in nine weeks;
- Per facility policy, a shower should be offered two times a week, which would be around 20 shower opportunities in a 60 day time period.
The facility did not provide dates staff assisted the resident with shaving.
8. Record review of Resident #78's annual MDS, dated [DATE], showed:
- Diagnoses included Alzheimer's disease (progressive mental deterioration), hypertension (high blood pressure), heart failure, and psychosis (a mental disorder with a severe loss of contact with reality);
- Severe cognitive impairment;
- Extensive assistance of one staff for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Occasionally incontinent of bowel and bladder.
Record review of shower sheets provided by facility for 10/1/21 through 12/2/21 showed:
- Shower received on 10/22/21;
- Shower received on 11/5/21, 14 days later;
- Shower received on 11/09/21;
- Shower sheet with documentation of refused 11/11/21;
- Shower received on 11/23/21, 14 days later;
- Shower received on 11/26/21;
- Per facility policy, a shower should be offered two times a week, which would be around 20 shower opportunities in a 60 day time period.
9. Record review of Resident #180's quarterly MDS, dated [DATE], showed:
- A admission date of 6/22/20;
- Severe cognitive impairment;
- Diagnoses include diabetes mellitus, Alzheimer's disease, Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), and depression;
- Requires extensive physical assistance of one staff for bathing.
During an interview on 12/1/21 at 9:45 A.M., Resident #180 said he/she last got a shower a week ago Tuesday. The resident asked what day it was today and when told Wednesday, he/she said it wasn't yesterday, it was a week ago on Tuesday.
Record review of shower sheets provided by facility for 10/1/21 through 12/2/21 showed:
- Shower received on 10/20/21;
- Shower received on 11/15/21, 27 days later;
- Shower received on 11/23/21, 8 days later;
- Per facility, policy a shower should be offered two times a week, which would be around 20 shower opportunities in a 60 day time period.
10. During an interview on 12/8/21 at 2:16 P.M., Registered Nurse (RN) F said the Certified Nurse Aides (CNAs) should complete the residents' showers per their shower days and as needed. The showers are documented on the bathing sheets and are turned into the nurses to review. The nurses are to review the shower sheets, but he/she isn't sure if that's actually being done. The shower sheets aren't placed in one particular spot, but are laid everywhere around the nurses' station offices so it is very hard to tell who has gotten a shower or not. He/she would expect the staff to notify him/her if a resident refused or didn't get a shower on their scheduled day, but he/she doesn't know if that is actually happening. He/she was unaware some residents were not being bathed per their bathing schedules.
During an interview on 12/8/20 at 2:40 P.M., CNA P said the CNA on the memory care unit (MCU), where Residents #49 and #71 reside, would be responsible for giving those resident's showers. There shouldn't be an issue on giving the showers on the MCU because the residents are either independent or don't take long to shower/bathe. He/she is unaware of any residents not getting a shower on the unit. He/she lets the nurse know when a resident refuses a shower.
During an interview on 12/09/21 at 11:57 A.M., the Administrator, Director of Nursing, Infection Preventionist, and Director of Operations said residents should be showered or bathed a minimum of twice a week, more often if they want as it is their choice. It is the responsibility of the charge nurse on each shift to ensure showers are done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide restorative nursing aide (RNA) care to ensure a resident with limited range of motion received appropriate treatment ...
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Based on observation, interview, and record review, the facility failed to provide restorative nursing aide (RNA) care to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one resident (Resident #36) out of 20 sampled residents. The facility's census was 81.
Record review of the facility's policy titled, Restorative Nursing Program, dated 12/1/17, showed:
- It is the policy of this facility that a resident with a length of stay greater than 90 days is given the appropriate treatment and services to maintain or improve his or her abilities and to achieve or maintain the highest practicable outcome;
- When a resident is discharged from direct therapy services and would benefit from a restorative nursing program, therapy may make further recommendations for restorative needs;
- A resident who has been identified as requiring restorative nursing will receive a care plan outlining their problem, goal and intervention;
- Program goals and approaches will be written on the Nursing Restorative Participation Record flow sheet. The Certified Nurse Aide (CNA) or other nursing personnel will document the resident's participation;
- The nurse will complete the quarterly progress note that will reflect the resident's tolerance and progress toward their goals;
- The care plans will be updated based on the resident's status.
Record review of Resident #36's medical record showed:
- admission date of 3/24/21;
- Diagnoses include unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with behavioral disturbance and Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) with unspecified complications;
- Physician's Order Sheet (POS), dated 12/1/21, showed an order, dated 4/16/21, resident discharged from skilled physical therapy services due to progress ceased at this time, resident is referred to restorative nursing program;
- The facility staff did not obtain specific orders of how many days per week of RNA and for how long the resident required;
- Comprehensive care plan, last revised 7/19/21, did not address restorative care.
Record review of the resident's quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 6/30/21, showed:
- Extensive physical assistance of one staff for bed mobility and dressing;
- Extensive physical assistance of two staff for personal hygiene;
- Total dependence on two staff for transfers, toileting, and bathing;
- Functional Limitation in Range of Motion (ROM): Impairment of upper and lower extremities on both sides;
- Restorative Nursing Program: No Active or Passive ROM in last seven days. No Training or Skill Practice in bed mobility, transfers, or dressing in the last seven days.
Record review of the resident's Restorative Nursing Progress Notes showed:
- On 6/17/21, resident completed upper extremity (UE) exercises. Attempted lower extremity (LE) exercise but got tired very fast and did not want to continue;
- On 6/21/21, resident refused to participate in treatment;
- On 7/22/21, resident completed UE strengthening. Unable to work on LE due to resident being in bed;
- On 7/23/21, resident participated in UE exercises, was very tired today so did not complete all;
- On 7/26/21, resident completed UE exercise;
- On 8/2/21, resident refused treatment today;
- On 8/13/21, resident completed UE strengthening;
- No further restorative nursing notes.
Observations of the resident showed:
- On 11/29/21 at 12:45 P.M., the resident lay in bed;
- On 11/30/21 at 9:40 A.M., the resident lay in bed;
- On 12/1/21 at 9:45 A.M. and 2:59 P.M., the resident lay in bed.
During an interview on 12/01/21 at 11:22 A.M., Restorative Aide (RA) O said he/she was hired on 11/16/21 and hasn't done any restorative care since then because he/she has been having to help with staffing.
During a telephone interview on 12/14/21 at 4:19 P.M., the Administrator said she would expect a resident with orders for restorative care to receive restorative care treatments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate care and services of a urinary catheter (a tube...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate care and services of a urinary catheter (a tube placed in the bladder to drain urine) and obtain physician's orders related to the use/care of the urinary catheter for two residents (Resident #4 and #29) out of 20 sampled residents. The facility's census was 81.
1. Record review of the facility's undated policy titled, Catheter Care, Urinary, showed:
- The purpose of this procedure is to prevent catheter-associated urinary tract infections;
- Input/Output: Observe the resident's urine level for noticeable increases or decreases. Maintain an accurate record of the resident's daily output, per facility policy and procedure.
Record review of the facility's undated policy titled, Measuring and Recording Intake and Output, showed if the resident refused the treatment, the reason(s) why and the intervention taken. Notify the supervisor if the resident refuses the procedure.
2. Record review of Resident #4's medical record showed:
- admitted [DATE];
- Diagnoses include benign prostatic hyperplasia (BPH: enlargement of the prostate causing difficulty in urination) with lower urinary tract symptoms, hypokalemia (decreased blood level of potassium), congestive heart failure (CHF: an inability of the heart to pump sufficient blood flow to meet the body's needs), retention of urine, and urinary tract infection (UTI).
Record review of the resident's Physician's Order Sheet (POS), dated 12/1/21, showed:
- An order, dated 6/16/21 with a start date of 6/17/21, for furosemide (a diuretic medication) 40 milligrams (mg) once daily related to retention of urine;
- An order, dated 6/16/21, for Foley catheter (urinary catheter: a tube placed in the bladder to drain urine) care every shift;
- An order, dated 6/30/21 with a start date of 7/1/21, for suprapubic (SP: a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the abdomen, a few inches below the belly button) catheter care daily and as needed (prn). Cleanse around catheter with wound cleanser, put drainage sponge around tube and secure with tape every day shift for SP catheter care;
- An order, dated 7/22/21, for urinary output every shift.
Record review of the resident's comprehensive care plan, last revised 10/19/21, showed:
- Change SP catheter as ordered;
- Empty catheter every shift and document output;
- Provide catheter care every shift.
Record review of the resident's Treatment Administration Record (TAR) showed:
- September 2021 TAR orders for SP catheter care not provided on 9/2/21, 9/9/21, 9/13/21, 9/18/21, 9/19/21, 9/24/21, 9/26/21, and 9/27/21. Eight opportunities missed out of 30 opportunities;
- October 2021 TAR orders for SP catheter care not provided on 10/2/21, 10/3/21, 10/10/21, 10/16/21, 10/23/21, 10/24/21, 10/26/21, and 10/31/21. Eight opportunities missed out of 31 opportunities;
- November 2021 TAR orders for SP catheter care not provided on 11/2/21, 11/4/21, and 11/13/21. Three opportunities missed out of 30 opportunities.
Record review of the resident's TAR showed:
- September 2021 TAR orders for foley catheter care not provided on day shift 9/2/21, 9/9/21, 9/10/21, 9/13/21, 9/18/21, 9/19/21, 9/24/21, 9/26/21, and 9/27/21, not provided on evening shift on 9/2/21, and 9/10/21, and not provided on night shift on 9/12/21. 12 opportunities missed out of 90 opportunities;
- October 2021 TAR orders for foley catheter care not provided on day shift 10/2/21, 10/3/21, 10/16/21, 10/23/21, 10/24/21, 10/26/21, and 10/31/21, not provided on evening shift 10/7/21, 10/24/21, and 10/25/21, and not provided on night shift 10/24/21, 10/25/21, and 10/26/21. 13 opportunities missed out of 93 opportunities;
- November 2021 TAR orders for foley catheter care not provided on day shift 11/2/21, 11/4/21 and 11/13/21, not provided on evening shift 11/12/21 and 11/17/21, and not provided on night shift 11/3/21, 11/12/21, 11/15/21, 11/16/21, 11/17/21, and 11/26/21. 11 opportunities missed out of 90 opportunities.
Record review of the resident's TAR showed:
- September 2021 TAR orders for urinary output every shift not provided on day shift 9/6/21, 9/8/21, 9/9/21, 9/10/21, 9/12/21, 9/13/21, 9/16/21, 9/17/21, 9/18/21, 9/19/21, 9/20/21, 9/23/21, 9/24/21, 9/26/21, and 9/29/21, not provided on evening shift 9/9/21, 9/10/21, 9/18/21, 9/19/21, 9/20/21, 9/24/21, 9/24/21, 9/28/21 and 9/29/21, and not provided on night shift 9/2/21, 9/11/21, 9/12/21, 9/15/21, 9/17/21, 9/18/21, 9/19/21, and 9/20/21. 32 opportunities missed out of 90 opportunities;
- October 2021 TAR orders for urinary output not provided on day shift 10/3/21, 10/7/21, 10/9/21, 10/13/21, 10/16/21, 10/17/21, 10/18/21, 10/21/21, 10/22/21, and 10/24/21, not provided on evening shift 10/6/21, 10/7/21, 10/21/21, 10/24/21, and 10/25/21, and not provided on night shift 10/1/21, 10/2/21, 10/3/21, 10/4/21, 10/5/21, 10/10/21, 10/11/21, 10/14/21, 10/16/21, 10/20/21, 10/22/21, 10/23/21, 10/24/21, 10/25/21, 10/26/21, and 10/28/21. 31 opportunities missed out of 93 opportunities;
- November 2021 TAR orders for urinary output every shift not provided on day shift 11/2/21, 11/4/21, 11/6/21, 11/8/21, 11/9/21, 11/13/21, 11/17/21, 11/18/21, 11/22/21, 11/27/21, and 11/28/21, not provided on evening shift 11/2/21, 11/3/21, 11/6/21, 11/7/21, 11/10/21, 11/11/21, 11/12/21, 11/16/21, 11/17/21, 11/20/21, 11/26/21, 11/29/21, and 11/30/21, and not provided on night shift 11/1/21, 11/3/21, 11/4/21, 11/7/21, 11/10/21, 11/12/21, 11/13/21, 11/15/21, 11/16/21, 11/17/21, 11/18/21, 11/20/21, 11/26/21, 11/27/21 and 11/28/21. 39 opportunities missed out of 90 opportunities.
3. Record review of Resident #29's medical record showed:
- An admission face sheet, admission date of 9/26/20, discharge date of 10/25/21 and readmission date of 11/8/21;
- Diagnoses included urinary retention (an inability to empty the bladder of urine) and neurogenic bladder (a condition in which problems with the nervous system affect the bladder and urination).
Record review of the resident's quarterly Minimum Data Set (MDS: a federally mandated assessment instrument completed by the facility), dated 7/8/21, showed:
- Alert and oriented;
- Required limited to extensive assistance from staff with Activities of Daily Living (ADLs);
- Indwelling urinary catheter.
Record review of the resident's POS, dated November 2021, showed:
- An order dated 11/17/21, to change urinary catheter every 30 days and catheter care every shift;
- No order for catheter size and/or balloon.
Record review of the resident's TAR, dated November 2021, showed:
- An order, dated 11/17/21, to change urinary catheter every 30 days;
- On 11/9/21 and 11/17/21, staff documented for the change of the resident's urinary catheter and provided no documentation on size of catheter and/or size of balloon that was inserted;
- An order, dated 11/17/21, to provide catheter care every shift;
- On 11/17/21, 11/18/21, 11/21/21, 11/23/21 and 11/26/21, staff left blank for providing catheter care and provided no explanation for the catheter care not being provided for six opportunities missed out of 42 opportunities.
Observation on 12/2/21 at 9:13 A.M., showed Licensed Practical Nurse (LPN) H and LPN M provided incontinence and catheter care on the resident. The resident had an indwelling urinary catheter, Size 18 French (the size of catheter) with 10 cubic centimeter (cc) balloon (the balloon portion of the catheter is inflated with saline solution to keep the catheter in the bladder).
4. During an interview on 12/9/21 at 11:55 A.M., the Director of Operations said nursing staff were responsible to obtain a physician's order regarding the size of the urinary catheter and balloon size and should be on the resident's current POS. She expected the nursing staff to have provided the resident's urinary catheter care every shift as ordered and should document the catheter care on the resident's TAR. She said if nursing staff left blank for providing the catheter care every shift on the resident's TAR, it means the catheter care was not done as ordered.
During an interview on 12/9/21 at 11:57 A.M., the Administrator, Director of Nursing, and Director of Operations said they would expect catheter care orders, including catheter changes and urinary output, to be followed and documented on the TAR, and the catheter size should be identified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order for oxygen use, change and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order for oxygen use, change and date the oxygen tubing (a flexible tubing that connects to the oxygen concentrator and delivers supplemental oxygen through the nostrils), fill the humidifier bottle (a bottle attached to an oxygen concentrator, filled with distilled water to moisten the air) per facility policy, and monitor oxygen saturation (amount of oxygen in a person's blood) per physicians orders. This practice affected one resident (Resident #12) out of 20 sampled residents. The facility's census was 81.
Record review of the facility's policy titled Oxygen Supplies Policy, dated 12/1/18, showed:
- This facility will maintain oxygen device supplies in a clean status, ensuring proper labeling and replacement of supplies as needed per physician's orders;
- Oxygen supplies will be changed according to physician's order or tubing will be changed according to facility's standard practice: oxygen tubing will be changed one time per week if oxygen is in use, distilled water containers for oxygen concentrators are replaced, as needed, oxygen concentrator filters should be removed and cleaned weekly;
- Oxygen tubing changes will be documented on the associated Treatment Administration Record (TAR)/Medication Administration Record (MAR);
- If additional documentation is required according to physician's order this will be also added to the resident's TAR.
Record review of Resident #12's medical record showed:
- admission date of 2/23/21;
- Diagnoses include pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
Record review of the resident's admission Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 3/6/21, showed:
- The brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 15 out of 15 which indicated the resident to be cognitively intact;
- Section O, 0100 J for oxygen therapy to be marked yes for while a resident and while not a resident.
Record review of the quarterly MDS, dated [DATE], showed:
- The BIMS score to be 14 out of 15 which indicated as the resident to be cognitively intact;
- Section O, 0100 J for oxygen therapy to be blank.
Record review of the resident's Physician's Order Sheet (POS), dated 12/1/21, showed :
- An order, dated 4/22/21, to take oxygen saturation every shift;
- No order for oxygen.
Record review of the resident's MAR showed:
- Dated 10/1/21 - 10/31/21 oxygen saturation documentation missed 19 of 93 opportunities;
- Dated 11/1/21 - 11/30/21 oxygen saturation documentation missed 25 of 90 opportunities;
- No documentation of changing oxygen tubing.
Record review of the comprehensive care plan, last updated 9/29/21, showed no care plan for oxygen.
Observation on 11/30/21 at 10:13 A.M., showed the resident lay in bed. A nasal cannula (a tube delivering oxygen to a person's nose) attached to the supplemental oxygen flowmeter lay on the floor beside the bed. The supplemental oxygen tube showed it to be four tubes connected within each other and with one connection secured with green tape. The supplemental oxygen tube did not contain a date of when it was placed in use. The humidifier bottle (a medical device used to increase the moisture in supplemental oxygen to alleviate a sore, dry/bloody nose while using the supplemental oxygen) to be 3/4 full of a clear liquid. The supplemental oxygen flowmeter set at three liters.
During an interview on 11/30/21 at 10:13 A.M., the resident said he/she uses oxygen sometimes. The resident needs a longer tube so he/she can move around the bed. The facility will not provide a longer tube so he/she saved shorter ones and cut the ends using toenail clippers then connected the tubes together. The resident said the facility does not change the tubing or fill the water bottle (the water bottle supplies humidification to the supplemental oxygen). The resident fills the water bottle with tap water. He/she would like to go play bingo in the dining room but the facility will not provide a portable oxygen tank for him/her to use during the activity so he/she does not go.
Observation on 12/2/21 at 9:25 A.M., showed the resident wore a nasal cannula attached to the supplemental oxygen flowmeter and the flowmeter set at three liters. The supplemental oxygen tube showed it to be four tubes connected within each other and with one connection secured with green tape, undated.
During an interview on 12/2/21 at 9:25 A.M., the resident said the facility has not changed the tubing.
Observation on 12/7/21 at 9:40 A.M., showed the resident wore a nasal cannula attached to the supplemental oxygen flowmeter and the flowmeter set at three liters. The supplemental oxygen tube showed it to be four tubes connected within each other and with one connection secured with green tape, undated.
During an interview on 12/2/21 at 9:40 A.M., the resident said the facility has not changed the tubing.
During an interview on 12/9/21 at 11:57 A.M., the Administrator said she would expect oxygen tubing to be changed and the humidifier to be filled as ordered. The Director of Operations said there are plenty of oxygen tanks in the building for one to be provided to a resident that wants to use one to move around the building. Staff are aware of where they are stored and have access to them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who displayed or was diagnosed with a mental disor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two residents (Residents #29 and #33) out of 20 sampled residents. The facility's census was 81.
The facility did not provide a policy which addressed mental disorder or psychosocial adjustment
1. Record review of Resident #29's medical record showed:
- An admission date of 9/26/20, discharge date [DATE], re-admission date 10/25/21, discharged [DATE] and re-admission date of 11/8/21;
- Diagnoses included major depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent worry and fear about everyday situations) disorder, urinary retention (inability to empty the bladder of urine) and schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions (false beliefs) and hallucinations (an experience involving the apparent perception of something not present).
Record review of the resident's quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 7/8/21, showed:
- Alert and oriented;
- Verbal behaviors directed towards other occurred 1 to 3 days;
- Required limited to extensive assistance from staff with Activities of Daily Living (ADLs);
- Indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine).
Record review of the resident's nurse's note/progress note, dated 10/25/21 at 7:30 A.M., the resident called 911 (emergency number) and told the emergency personnel he/she was suicidal (deeply unhappy or depressed, likely to commit suicide), with a plan, and was in pain. Emergency Medical Service (EMS) arrived to the facility. The resident verbalized he/she would rip his/her catheter out and choke him/her self with the catheter. EMS transported the resident to the hospital for an evaluation. The resident's physicians were notified.
Record review of the resident's health status note, dated 10/25/21 at 11:57 A.M., staff documented during the course of the resident's evaluation in the hospital emergency room, spoke with hospital social worker and nursing staff, resident is medically cleared and counseling reports he/she needs to be monitored for his/her ideations. The facility will accept the resident back and send to another facility for psychiatric care.
Record review of the resident's social service progress notes showed:
- On 10/25/21 at 8:06 A.M., the resident once again called 911 stating he/she had not had a bowel movement (BM) in three days. The resident was taken to the hospital for evaluation and treatment;
- On 12/1/21 at 10:35 A.M. (late entry), follow up from hospitalization regarding suicidal ideations. Upon return from the hospital on [DATE], resident appears to be doing fine. The resident stated he/she really didn't want to commit suicide, but he wanted to go to the hospital because he/she had not had a BM in three days;
- No other weekly social service notes regarding the resident's suicidal ideation's and/or psychosocial well-being.
During an interview on 12/1/21 at 10:22 A.M., the social service designee verified he/she did not follow up with the resident on a weekly basis regarding his/her suicidal ideations when he/she was discharged to the hospital on [DATE]. The social service designee said he/she should have followed up with the resident, but did speak with the resident after he/she returned from the hospital on [DATE] about his/her psychosocial well-being. The social service designee said he/she could put a late note in regarding their conversation when the resident returned to the facility from the hospital.
During an interview on 12/9/21 at 11:55 A.M., the Director of Operations said she expected the social service designee to have followed up with the resident at least two to three times a week regarding the resident's suicidal ideations and psychosocial well-being. The resident should have been monitored every 15 minutes by nursing staff when he/she returned to the facility for 72 hours regarding his/her suicidal ideations.
Further review the resident's medical record, showed no documentation nursing staff provided 15 minute checks/monitoring for at least 72 hours after the resident returned from the hospital related to his/her suicidal ideations.
The facility did not follow up and obtain any type of treatment from other resources related to the suicidal ideations.
2. Record review of Resident #33's medical record showed:
- Original admission date 4/22/19 with readmission date of 11/12/21;
- Diagnoses include chronic pain, major depressive disorder, Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), transient cerebral ischemic attack (TIA: a neurologic deficit that produces stroke symptoms that resolve within 24 hours), atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries causing obstruction of blood flow), and mood disorder (a condition which causes a person's emotional state to be distorted and interferes with the ability to function).
Record review of the resident's progress notes dated 11/4/21 showed:
- At 4:12 P.M., resident reported to another nurse that he/she never gets pain medicine and has been in pain and that the resident wants to commit suicide. Resident asked the nurse if he/she gave the resident pain medicine the day he/she worked and the nurse said no, then told this writer to report it. Resident stated he/she has a 6 out of 10 pain down his/her back currently. Resident also stated he would not commit suicide nor has he/she told anyone that he/she would;
- At 4:34 P.M., notified physician of resident's pain and prior statement that he/she was suicidal, but denied it to this writer and the physician gave orders to send resident out for his/her statement;
- At 5:20 P.M., the Director of therapy came to let this writer know, a resident on A hall had stated the resident was going to commit suicide. During assessment, Resident #33 stated he/she was in a lot of leg pain. Went to look at the resident's MAR and reported the incident to A hall nurse. Let A wing nurse know the prn pain pill the resident had was Tylenol 325 2 tabs. Then let A wing nurse know the incident needed to be reported to the resident's provider;
- At 9:04 P.M., received report from hospital, resident being discharged back, knee x-ray normal;
- At 9:35 P.M., responsible party notified of resident returning from emergency room and of transporting to a psychiatric hospital;
- No social service notes following up on hospital stay for suicidal ideations.
The facility did not follow up and obtain any type of treatment from other resources related to the suicidal ideations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, develop, and implement an individualized appr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, develop, and implement an individualized approach to providing dementia care services for four residents (Residents #36, #52, #78, and #334) out of five sampled residents. The facility's census was 81.
1. Record review of Resident #36's medical record showed:
- Original admission date of 12/23/19 with readmission date of 3/24/21,
- Diagnoses of dementia (disorder marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) with behavioral disturbance, major depressive disorder (long-term loss of pleasure or interest in life), chronic pain (pain that is ongoing and usually lasts longer than six months), hypertension (high blood pressure), and Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar).
Record review of the resident's Physician's Order Sheet (POS), dated 12/1/21, showed:
- An order, dated 4/9/21, for donepezil HCL 10 milligrams (mg) once daily for dementia with behavioral disturbance;
- An order, dated 4/9/21, for quetiapine fumarate (an antipsychotic medication) 50 mg three times daily related to dementia with behavioral disturbance and major depressive disorder.
Record review of the resident's comprehensive care plan, last reviewed 7/19/21, showed no plan of care for dementia.
2. Record review of Resident #52's medical record showed:
- admission date of 1/31/19;
- Diagnoses include dementia, and chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Record review of the resident's quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 7/15/21, showed:
- The brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 10 out of 15 which indicated the resident to be moderately cognitively impaired:
- Extensive assistance of one staff for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Frequently incontinent of bowel and bladder.
Record review of the resident's comprehensive care plan, last updated 7/13/21, showed no care plan for dementia.
3. Record review of Resident #78's annual MDS, dated [DATE], showed:
- Diagnoses included Alzheimer's disease (progressive mental deterioration), hypertension, heart failure (condition in which the heart does not pump blood as well as it should), and psychosis (a mental disorder with a severe loss of contact with reality).
- Resident is severely cognitively impaired;
- Extensive assistance of one staff for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Occasionally incontinent of bowel and bladder.
Record review of the resident's POS, dated 12/01/21, showed:
- Diagnoses of Alzheimer's disease, hypertension, heart failure and psychosis;
- No medications being given for diagnosis of Alzheimer's dementia.
Record review of the resident's comprehensive care plan, last reviewed 11/5/21, showed no plan of care for dementia.
4. Record review of Resident #334's medical record showed:
- admission date of 4/26/19;
- Diagnoses include bipolar disorder (mental disorder that causes unusual shifts in mood), Alzheimer's disease , diabetes mellitus, major depressive disorder-recurrent (long-term loss of pleasure or interest in life), and chronic kidney disease (a gradual loss of kidney function).
Record review of the resident's annual MDS, dated [DATE], showed:
- The BIMS score to be 10 out of 15 which indicated the resident to be moderately cognitively impaired:
- Extensive assistance of one staff for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Frequently incontinent of bowel and bladder.
Record review of the resident's comprehensive care plan, last updated 8/27/21, showed no care plan for dementia.
5. During interview on 12/09/21 at 11:57 A.M., the Director of Nursing and Administrator said they would expect a resident with a diagnosis of dementia to have a dementia care plan. The MDS Coordinator is responsible for the care plan.
The facility did not provide a policy for dementia care planning.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation in regards to the gradual dose reductions (GDR) for antidepressant and antipsychotic (medications used to treat mood and bipolar disorders) medications for one resident (Resident #71) out of 20 sampled residents. The facility's census was 81.
Record review of the facility's policy titled, Use of Psychotropic Drugs policy, dated 12/1/16, showed:
- Each resident's drug regimen will be free from unnecessary drugs, including unnecessary antipsychotic drugs;
- Residents who have not used antipsychotic drugs will not be given these drugs unless
antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and
documented in the clinical record;
- Antipsychotic medications must be prescribed at the lowest possible dosage for the shortest period of time and will be subject to a GDR and review;
- The physician will document the clinical rationale for why any attempted GDR would likely impair the resident's function or increase the distressed behavior.
Record review of Resident #71's Physician Order Sheet (POS), dated December 2021, showed:
- Diagnoses of dementia (a brain disease which may cause a decrease in thinking ability) without behavioral disturbance and major depressive disorder (a mental disorder characterized by a persistently depressed mood);
- An order for Seroquel (antipsychotic) 25 milligram (mg) twice daily for mood, dated 4/21/21;
- An order for Seroquel 50 mg three times daily for dementia without behavioral disturbance, dated 2/18/21;
- An order for Lexapro (antidepressant) 10 mg [NAME] for major depressive disorder, dated 7/14/21.
Record review of the pharmacist's Medication Regimen Review Prescriber Recommendation form, dated 9/24/21, showed:
- The resident received Seroquel 50 mg three times daily for mood, Seroquel 25 mg twice daily for mood, and Lexapro 10 mg daily for depression;
- Request for GDR for all of the psychotropic (any medication that affects behavior, mood, thoughts, or perception) medications;
- The prescriber note (required documentation) with a clinical rationale for why an attempted GDR would impair function or cause psychiatric instability and exacerbate an underlying medical/psychiatric disorder left blank of any documentation;
- The prescriber check marked the choice on the form of patient is stable and functioning at the highest level on the current dose of medication. A GDR would be detrimental. The benefits of a GDR do not outweigh the risks and are clinically contraindicated;
- The prescriber's response was left blank;
- The prescriber signed on 10/1/21;
- The facility did not receive the prescriber's documentation of the detailed clinical rationale for the Seroquel and Lexapro GDR refusals.
During an interview on 12/9/21 at 11:57 A.M., the Administrator said she would expect the residents to be free of unnecessary medications. The Director of Nursing (DON) is responsible in assuring the physician responds to the pharmacist's recommendations. The DON just started on 11/29/21 and we have recently had some transitional moves within our nursing staff. She just started about two months ago and is unsure who was responsible for assuring the physician responded to the pharmacist's recommendation during that timeframe. She would expect a response from the physician to the pharmacist's requests within one week.
During a telephone interview on 12/14/21 at 10:25 A.M., the Pharmacy Consultant said he/she has provided a choice on the Medication Regimen Review Prescriber Recommendation form for the prescriber to check mark, If a patient is stable and functioning at the highest level on the current dose of medication. A dosage reduction would be detrimental. The benefits of a reduction do not outweigh the risks and are clinically contraindicated., due to so many of the prescribers not documenting their clinical rationale for a GDR refusal. He/she was unaware the prescriber needed to personally document in detail the clinical rationale for a GDR refusal.
During a telephone interview on 12/30/21 at 10:30 A.M., the Psychiatric Nurse Practitioner said each pharmacy has their own MRR forms. Some of the forms, such as the form for Resident #71, have specific responses that the practitioner can just check mark, so he/she didn't realize documentation of the detailed clinical rationale for the psychotropic GDR refusals was needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic (a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic (a major tranquilizer) medication for one resident (Resident #71) out of five sampled residents. The facility's census was 81.
Record review of the facility's policy titled, Use of Psychotropic Drugs policy, dated 12/1/16, showed:
- Each resident's drug regimen will be free from unnecessary drugs, including unnecessary antipsychotic drugs;
- Residents who have not used antipsychotic drugs will not be given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record;
- Antipsychotic medications must be prescribed at the lowest possible dosage for the shortest period of time and will be subject to a gradual dose reduction (GDR) and review;
- The physician will document the clinical rationale for why any attempted GDR would likely impair the resident's function or increase the distressed behavior.
Record review of Mosby's 2021 Nursing Drug Reference for antipsychotic medications showed:
- Contraindications for geriatric patients;
- Black box warning for increased mortality in the elderly patients with dementia.
Record review of Resident #71's Physician's Order Sheet, dated December 2021, showed:
- Diagnoses of dementia (a brain disease which may cause a decrease in thinking ability) without behavioral disturbance and major depressive disorder (a mental disorder characterized by a persistently depressed mood);
- An age of [AGE] years old;
- An order for Seroquel (an anti-psychotic used to treat mental/mood conditions) 25 milligram (mg) twice daily for mood, dated 4/21/21;
- An order for Seroquel 50 mg three times daily for dementia without behavioral disturbance, dated 2/18/21.
Record review of the pharmacist's Medication Regimen Review Prescriber Recommendation form, dated 9/24/21, showed:
- The resident received Seroquel 50 mg three times daily for mood and Seroquel 25 mg twice daily for mood;
- The pharmacist requested an appropriate diagnosis for the antipsychotic medication use;
- The presriber's response was left blank;
- The prescriber signed on 10/1/21;
- The facility did not receive an appropriate diagnosis for the Seroquel.
During an interview on 12/9/21 at 11:57 A.M., the Administrator said she would expect the residents to be free of unnecessary medications. The Director of Nursing (DON) is responsible in assuring the physician responds to the pharmacist's recommendations. The DON just started on 11/29/21, and we have recently had some transitional moves within our nursing staff. She just started about two months ago and is unsure who was responsible for assuring the physician responded to the pharmacist's recommendation during that timeframe. She would expect a response from the physician to the pharmacist's requests within one week.
During a telephone interview on 12/30/21 at 10:30 A.M., the Psychiatric Nurse Practitioner said each pharmacy has their own MRR forms. Since the forms look different, he/she didn't realize the pharmacist was asking for an appropriate diagnosis for the Seroquel for Resident #71. Therefore, he/she didn't review and provide an appropriate diagnosis for the resident's Seroquel.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide or arrange for dental services for one reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide or arrange for dental services for one resident (Resident #57) outside of the 20 sampled residents. The facility's census was 81.
Record review of Resident #57's medical record showed:
- admission date of 2/14/19 and own responsible party (RP);
- A guardianship document, dated 9/13/21, to show the resident's family member to be the RP;
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), and pain.
Record review of the annual Minimum Data Set (MDS: a federally mandated assessment completed by the facility staff) dated 2/5/21, showed:
- The brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score not to be completed;
- Extensive assistance for bed mobility, dressing, eating, and toileting;
- Totally dependent on one staff for transfers, personal hygiene, and bathing;
- Always incontinent of bowel and bladder;
- Section L 0200, Dental, marked obvious or likely cavity or broken teeth.
Record review of the resident's quarterly MDS, dated [DATE], showed:
- BIMS to be score to be 14 out of 15 which indicated the resident to be cognitively intact;
- Section L 0200 Dental, marked 'none of the above' for dental concerns.
Record review of the resident's December 2021 Physician's Order Sheet (POS) showed an order, dated 3/20/20, for resident may see dentist as needed.
Record review of the resident's Comprehensive Care Plan, last updated 10/21/21, showed the resident required assistance with brushing teeth.
Observations showed:
- On 11/29/21 at 1:10 P.M., the resident's teeth to be black, broken and food to be between his/her lips, gums and teeth;
- On 12/1/21 at 9:15 A.M., the resident's teeth to be black, broken and food to be between his/her lips, gums and teeth;
- On 12/8/21 at 1:55 PM., the resident's teeth to be black, broken and food to be between his/her lips, gums and teeth.
- On 12/9/21 at 2:00 PM., the resident's teeth to be black, broken and food to be between his/her lips, gums and teeth.
During an interview on 12/1/21 at 9:15 A.M., the resident said the facility staff do not take care of him/her.
During an interview on 12/1/21 at 7:47 P.M., the resident's RP said the resident used to have beautiful white teeth. The last time the RP was able to see the resident, his/her teeth were black and broken The RP does not believe the facility staff are taking care of the resident's teeth.
During an interview on 12/9/21 at 2:00 P.M., the resident said no one has helped him/her brush his/her teeth since he/she was admitted over a year ago. The Administrator present during interview and made no comment.
During an interview on 12/9/21 at 11:57 A.M., the Administrator and Director of Nursing said they would expect a resident's teeth to be brushed daily. The Administrator said she would expect dental services to be provided as needed for all residents.
During an interview on 1/6/22 at 9:22 A.M., the Administrator said the residents can be sent out to a dentist if they are in pain. A dental provider comes to the facility on a regular basis to see residents.
Record review of an email, dated 1/6/22 at 4:03 P.M., the administrator showed Resident #57 refuses to go to all physician appointments. He/she is scheduled for a dental appointment on 2/19/22. The facility will be encouraging him/her to go to this appointment.
Record review of an email, dated 1/6/22 at 8:19 P.M., the administrator showed Resident #57 to have no dental appointments scheduled and/or refused between 1/5/21 and 1/6/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to provide food in a form designed to meet individual needs for one resident (Resident #57) outside of the 20 sampled residents. ...
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Based on observation, record review and interview, the facility failed to provide food in a form designed to meet individual needs for one resident (Resident #57) outside of the 20 sampled residents. The facility's census was 81.
1. Record review of the facility's policy titled, Policy and Procedure; Admission, dated 1/19, showed:
- Medications, treatments or special diets will be offered to the resident if ordered by physician, the facility Medical Director or any other physician approved by either of them or the resident;
- The facility will exercise reasonable care toward the resident to ensure residents needs are met while residing at the facility.
2. Record review of Resident #57's medical record showed:
- An admission date of 2/14/19;
- Diagnoses included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain.
Record review of the resident's quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 5/5/21, showed:
- The brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 indicated the resident to be cognitively intact;
- Extensive assistance for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
Record review of the resident's Physician's Order Sheet (POS), dated 12/2/21, showed:
- An order, dated 1/29/21, for regular diet, mechanical soft texture, regular consistency;
- An order, dated 3/29/21, for finger foods may be given as resident prefers as resident also prefers a mechanical soft diet.
Record review of the resident's comprehensive care plan, last updated 10/21/21, showed:
- Staff should provide the resident with finger foods when he/she has difficulty using utensils;
-Staff should continue with the resident's diet as ordered and continue to make sure to serve meals in his/her divided plate and cup with lid;
- Staff should tell the resident where items are located in a consistent manner. Explain to the resident what food is on his/her plate and placement of napkin, drinks, silverware and TV remote is on his/her bedside table.
Observations showed:
- On 11/29/21 at 1:10 P.M., the resident lay in bed with the bedside table over his/her bed, the table with three foam cups containing liquid, without lids, one plastic cup containing liquid, without a lid, a plastic knife and spoon, an eight ounce size carton of milk with a straw, liquid spilled and standing on the table, the bed sheets with stains of food and liquid;
- On 12/1/21 at 9:15 A.M., the resident lay in bed with bedside table over his/her bed, the table with a mug of yellow liquid, without a lid, two open containers of jell-o and a piece of jell-o to lay on the resident's chest;
- On 12/8/21 at 1:55 P.M., the resident lay in bed with the bedside table over his/her bed, a towel over his/her chest, the table with an undivided plate with ravioli with red sauce spilled onto the bedside table and bed sheets, a bowl of corn spilled over table, bed and the resident, and graham cracker crust crumbs smeared over the table, the bed sheets and the resident. The resident was upset.
During an interview on 12/7/21 at 9:40 A.M., the resident said she has requested boiled eggs for over a year and still gets scrambled eggs. He/she cannot eat scrambled eggs. He/she got soured milk on his/her tray this morning.
During an interview on 12/8/21 at 1:55 P.M., the resident, speaking loudly, said he/she needs food he/she can eat with a spoon or finger foods, they know this and they keep bringing food he/she cannot eat. They do not tell him/her where the food is located on the plate, they just sit it down and leave.
During an interview on 12/9/21 at 11:57 A.M., the Administrator and Director of Operations said they would expect food to be served in a manner that accommodates the resident's needs to identify where it is and how it can be eaten.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide food that accommodates a resident's allergies, intolerance's and preferences and offer appealing options of similar nutritive value...
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Based on interview and record review, the facility failed to provide food that accommodates a resident's allergies, intolerance's and preferences and offer appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for two residents (Residents #57 and #329) outside of the 20 sampled residents. The facility's census was 81.
1. Record review of the facility's policy titled, Resident Rights Policy, dated 12/1/19, showed:
- It is the policy of this facility to provide quality healthcare through communication, respect, and sensitivity between the residents and those who provide them care. Our facility strives to promote the exercise of right for each resident, even if he or she is determined to be incompetent, should be able to assert these rights based on his or her degree of capability;
- Resident are able to make choices about his or her own life subject the the facility's rules, as long as those rules do not violate a regulatory requirement;
- Residents should participate in planning their care, which includes daily schedules.
The facility did not provide a policy regarding food choices or alternate meals.
2. Record review of Resident #57's medical record showed:
- An admission date of 2/14/19;
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain.
Record review of the resident's quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 5/5/21, showed:
- The brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 indicated the resident to be cognitively intact;
- Extensive assistance for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
Record review of the resident's comprehensive care plan, last updated 10/21/21, showed:
- The resident received a mechanical soft diet and finger foods on a divided plate and cups with lids, straws and will continue making self dietary choices. Staff will continue to let the resident make dietary choices.
- The resident is visually impaired and to maintain optimal quality of life staff should assist by consistently explaining where items are located, such as the food on meal trays, silverware, TV remote, etc
During an interview on 12/07/21 at 9:40 A.M., Resident #57 said he/she has requested boiled eggs for over a year and still gets scrambled eggs. Resident #57 does not like scrambled eggs and cannot eat them.
The facility did not meet the individual needs for the resident with meals.
3. During individual Resident Council interviews on 11/29/21 at 11:58 A.M., Resident #329 said the menus never change with the seasons, the residents do not get to choose what they want to eat, they get what they are given. Resident #329 does not like bologna but he/she is not offered an alternate if that is what is being served. The resident is allergic to sweet potatoes but they are on his/her plate anyway. The Resident Council members bring it to staff attention all the time but they don't do anything. The residents would like to get tea and/or soda and they do not.
Record review of the Resident Council minutes showed:
- On 9/8/21, Residents asked for menus to be passed out, states they are getting food on their don't like list;
- On 10/6/21, Residents asked for menus to be passed out or put up on the board, states they are getting food on their don't like list;
- On 11/10/21, Residents asked for menus to be passed out and filled out, want more alternatives less sandwiches, states they are getting food on their don't like list, want eggs changed up for breakfast, want bigger portions.
During an interview on 12/9/21 a 11:57 A.M., the Regional Dietary Manager said she would expect the resident's food preferences to be honored and for there to be enough food to satisfy the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This deficient practice had the potential to affect all residents. The facility'...
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Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This deficient practice had the potential to affect all residents. The facility's census was 81.
Record review of the facility's undated Meal Times showed Breakfast at 7:00 A.M., Lunch at 12:00 P.M., and Dinner at 5:00 P.M.
Observation on 11/29/21 of the Main Dining Room showed:
- At 12:04 P.M., six residents sat at tables waiting for lunch to be served;
- At 12:30 P.M., lunch still not being served;
- At 12:40 P.M., lunch still not being served;
- At 2:18 P.M., the last hall tray cart delivered at 2:18 P.M.
Observation of the kitchen on 11/29/21 at 1:28 P.M. showed dietary staff finished filling the B Wing food cart, one hour and 28 minutes past the listed meal time.
During an interview on 11/29/21 at 1:52 P.M., dietary aid (DM) N said they ran out of vegetables and had to make more, that is why the meal was late.
Observation of the kitchen on 11/30/21 at 1:35 P.M., dietary staff finished filling the 200 hall food cart, one hour and 35 minutes past the listed meal time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, facility staff failed to keep responsible party information accessible to staff for one resident (Resident #57) outside of the 20 sampled residents. The facility'...
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Based on interview and record review, facility staff failed to keep responsible party information accessible to staff for one resident (Resident #57) outside of the 20 sampled residents. The facility's census was 81.
1. The facility did not provide a policy for medical record updates.
2. Record review of Resident #57's medical record showed:
- admission date of 2/14/19 and the resident as his/her own responsible party (RP);
- A guardianship document, dated 9/13/21, to show the resident's sister as the RP;
- Diagnoses included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain;
- The quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 5/5/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 indicating the resident to be cognitively intact.
- The comprehensive care plan, last updated 10/21/21, showed:
Problem: I do not reach out to family and prefer not to have contact with them;
Goal: I will maintain the ability to seek social contact and stimulation through the review date;
Approach: Encourage me to participate in conversation with staff, other residents daily, assist me with my phone as needed, provide me with as many situations as possible which give me control over my environment and care delivery.
During an interview on 12/1/21 at 9:15 A.M., the resident said he/she is his/her own RP.
Record review showed the guardianship document located in the electronic medical record under miscellaneous documents to have no phone number for the guardian.
During an interview on 12/1/21 at 9:48 A.M., the Social Worker (SW) said the resident's sister is his/her guardian. The guardianship document is located in the electronic medical record under miscellaneous documents. The RP's phone number should have been updated in the medical record, it is somewhere in an email. The SW said it should be readily available to staff and she would update the phone number today.
During an interview on 12/1/21 at 10:22 A.M., the admission Coordinator said the resident is his/her own responsible party as far as she knows.
During interview on 12/01/21 at 1:54 P.M., the resident said he/she did not know that his/her sister is his/her guardian.
During a telephone interview on 12/01/21 at 7:47 P.M., the RP said she has been trying for months to communicate with the facility about the resident's care and condition No one will call her back and no one will help her make contact with the resident, even though she pays for a phone for the resident to use. The RP has not been notified of any change of condition and is unable to obtain any information about the resident. The facility tried to force guardianship with a public administrator because the resident refused to take antipsychotics (medications used to treat psychotic disorders, bipolar disorder and depression), at that time the RP took guardianship to prevent a public administrator guardianship. The RP believes the resident is capable of being his/her own RP.
Record review of the resident's nurse progress note, dated 12/2/21, at 1:44 A.M., showed on 12/1/21 at 8:20 P.M. the resident was transferred to a hospital, At 8:35 P.M., an attempt was made to contact guardian but was unsuccessful.
During a telephone interview on 12/2/21 at 7:46 A.M., the RP said she received a call from a hospital last evening, informing her the resident had been transferred there and they requested permission for treatment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect when staff provided plastic or styrofoam dinnerware. This effected all residents who...
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Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect when staff provided plastic or styrofoam dinnerware. This effected all residents who ate in the dining rooms. The facility also failed to ensure one resident, (Resident #57) outside the sample of 20 residents, had a clean bed and room, honored his/her preferences and assisted with the telephone. Additionally, the facility also failed to treat one resident, (Resident #76) out of 20 sampled residents, with dignity and respect when staff did not provide a clean, sanitary space to take meals in his/her room. The facility's census was 81.
1. Record review of the facility's policy titled, Resident Rights Policy, dated 12/1/19, showed:
- It is the policy of this facility to provide quality healthcare through communication, respect and sensitivity between the residents and those who provide them care. The facility strives to promote the exercise of rights for each resident, even if he or she is determined to be incompetent, should be able to assert these rights based on his or her degree of capability;
- Dignity, privacy and respect, Right to be treated with consideration and respect for personal dignity in privacy in living arrangements, personal care, medical care, communication, visits, meetings.
2. Observation of the Memory Care Unit (MCU) dining room on 11/29/21 at 1:21 P.M., showed:
- The residents served the lunch meal on regular plates with plasticware, drinks in foam cups, and dessert in foam-hinged containers;
- Staff and residents struggled to cut up approximately two inch thick pork tenderloin with plastic forks and knives;
- Staff and residents struggled to pick up pork tenderloin pieces with plastic forks;
- The facility staff did not provide non-disposable cutlery, glasses/cups, and dessert plates.
Observation of the MCU dining room on 11/30/21 at 1:03 P.M., showed:
- The residents served the lunch meal on regular plates with plasticware, drinks in foam cups, and dessert in in foam-hinged containers;
- The facility staff did not provide non-disposable cutlery, glasses/cups, and dessert plates.
3. Observation of the kitchen and Main Dining Room on 11/29/21 at 1:22 P.M. showed:
- The residents served the lunch meal on regular plates with plastic silverware and dessert in foam hinged containers;
- The facility staff did not provide non-disposable cutlery, glasses/cups, and dessert plates.
During an interview on 12/1/21 at 9:03 A.M., the Dietary Manager (DM) said the facility ran out of foam plates so the staff had to start using regular plates. Until the facility has enough staff to gather dishes and bring them to the kitchen, the facility will keep using the plastic silverware and foam dishware.
4. Record review of Resident #57's medical record showed:
- admission date of 2/14/19;
- A guardianship document, dated 9/13/21, to show the resident's sister to be the responsible party (RP);
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain.
- The quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 5/5/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 indicating the resident to be cognitively intact.
- Extensive assistance for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Always incontinent of bowel and bladder.
During interviews:
- On 11/29/21 at 1:10 P.M., the resident said it is like a prison here, he/she hates this place, they treat you worse than a prisoner;
- On 12/1/21 9:15 A.M., the resident said this place is 'Hell', he/she wants to move and has told the Social Worker (SW) about it many times and no one will help him/her. The SW never comes back and is never available;
- On 12/1/21 at 1:25 P.M., the resident's RP said he/she is unable to reach the resident. No one will take the resident a phone or help him/her receive a call on the phone that the RP pays for. The RP has been doing all he/she knows to do to get the resident moved, but no one will call him/her back to discuss anything.
Observations showed:
- On 11/29/21 at 1:10 P.M., the resident lay in bed covered with a sheet stained with brown liquid and food particles and a telephone sat on the nightstand, out of the resident's reach;
- On 12/1/21 at 9:15 A.M., the resident lay in bed covered with a sheet with a piece of red gelatin on the resident's chest and a telephone to sit on the nightstand, out of the resident's reach;
- On 12/08/21 at 1:55 PM., the resident lay in bed with a towel laid over his/her chest, lunch of ravioli with sauce, corn, and something with graham cracker crust smeared over the bedside tray, the sheet and bed. Pieces of food in the resident's hair. The resident's teeth with a jagged, broken black appearance. Particles of food settled in around the resident's lips, gums and teeth. A telephone sat on the nightstand and out of the resident's reach.
5. Record review of Resident #76's medical record showed:
- admission date of 4/8/19;
- Diagnoses include venous insufficiency (difficulty with blood returning to the heart from the legs), depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic pain (pain that is ongoing and usually lasts longer than six months).
Observations showed:
- On 11/29/21 at 1:31 P.M., a urinal sat on the resident's bedside table. The bedside table used during meals;
- On 11/30/21 at 8:37 A.M., a urinal sat on the bedside table and it contained 300 ml (milliliters) of urine in it. The urinal sat next to his/her breakfast plate;
- On 12/1/21 at 9:05 A.M., a urinal sat on the beside table and it contained 100 ml of urine in it. The urinal sat next to his/her breakfast plate;
- On 12/2/21 at 9:35 A.M., a urinal sat on the resident's bedside table;
- On 12/7/21 at 9:30 A.M., a urinal sat on the resident's bedside table;
- On 12/8/21 at 10:50 A.M., a urinal sat on the resident's bedside table.
6. During an interview on 12/9/21 at 11:57 A.M. the Administrator said she would expect residents to be respected by assisting them with their goals, choices and preferences. She would not expect a urinal to sit on a bedside table next to food and would expect a clean environment to be provided. The Regional Dietary Manager said she would expect there to be adequate dietary staff to collect the dishes and clean them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to allow unrestricted visitation to one resident (Resident #39) outside of the 20 sampled residents when the facility required a...
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Based on observation, interview, and record review, the facility failed to allow unrestricted visitation to one resident (Resident #39) outside of the 20 sampled residents when the facility required a family to make an appointment to visit with Resident #39. The facility also posted a sign which stated visitation was by appointment only. The facility's census was 81.
Record review of the facility's policy titled, Visitation Policy, dated 12/1/16, showed:
- The facility will make every effort to accommodate family members, friends, and other guests to be able to visit with a resident in a setting and time frame of their choosing, as long as the rights of the other residents are respected;
- The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to the resident's right to deny or withdraw consent at any time;
- The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time.
Record review of the facility's policy titled, COVID (an infectious disease caused by the SARS-CoV-2 virus) Infection Control, dated 4/2020, showed:
- The purpose of this policy is to outline preventative measures put in place to minimize the spread of the COVID-19 virus;
- All visitors have been restricted unless deemed a medical necessity or end of life care.
Record review of Centers for Medicare & Medicaid Services (CMS) Memorandum QSO-20-39-NH Guidance: Nursing Home Visitation - COVID-19, revised 11/12/21, showed visitation is now allowed for all residents at all times.
Observation on 11/29/21 at 9:00 A.M., showed the front entrance to the facility locked and a sign on the door which stated Visitation by appointment only.
Observation on 12/7/21 at 10:30 A.M., showed the front entrance to the facility locked and a sign on the door which stated Visitation by appointment only.
Observation on 12/7/21 at 10:31 A.M., of Resident #39 showed:
- The resident sat in a geri chair (a reclining chair on wheels) in the front lobby.
- The resident's two family members, who wore masks, sat in chairs approximately six feet away from the resident;
- The resident did not wear a mask.
During an interview on 12/7/21 at 10:32 A.M., Resident #39's family members said they called on 12/6/21 to make an appointment to visit Resident #39.
During a telephone interview on 12/16/21 at 3:22 P.M., the Administrator said she isn't sure when the facility started allowing visitors back into the building but it was prior to her employment and they require visitors to make an appointment to visit residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
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 complete a comprehensive Minimum Data Set (MDS: a federally manda...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to complete a comprehensive Minimum Data Set (MDS: a federally mandated assessment instrument completed by the facility staff) within the required timeframes for six residents (Residents #4, #7, #29, #67, #76, #129) out of 20 sampled residents and six residents (Resident #6, #24, #46, #53, #54, and #130) outside the sample. The facility's census was 81.
1. Record review of Resident #4's MDS records showed:
- admitted to the facility on [DATE];
- An admission MDS dated [DATE];
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
2. Record review of Resident #6's MDS records showed:
- admitted to the facility on [DATE];
- admission MDS completed on 9/16/20;
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
3. Record review of Resident #7's MDS records showed:
- admitted to the facility on [DATE];
- admission MDS dated [DATE];
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
4. Record review of Resident #24's MDS records showed:
- admitted to the facility on [DATE];
- admission MDS completed on 9/19/20;
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
5. Record review of Resident #29's MDS records showed:
- admitted to the facility on [DATE];
- admission MDS completed on 10/8/20;
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
6. Record review of Resident #46's MDS records showed:
- admission to the facility on [DATE];
- Annual MDS completed 10/2/20;
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
7. Record review of Resident #53's MDS records showed:
- admitted to the facility on [DATE];
- Annual MDS completed 10/20/20;
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
8. Record review of Resident #54's MDS records showed:
- admitted to the facility on [DATE];
- Annual MDS completed on 10/28/20;
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
9. Record review of Resident #67's MDS records showed:
- admitted to the facility on [DATE];
- Annual MDS completed 10/7/20;
- An incomplete annual MDS dated [DATE];
- The facility failed to fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
10. Record review of Resident #76's MDS records showed:
- admitted to the facility on [DATE];
- Annual MDS completed 4/3/20;
- Quarterly MDS completed 3/29/21(not an annual MDS as should have been scheduled);
- Annual MDS completed 7/30/21, almost four months past the date due;
- The facility did not complete the appropriate MDS on 3/29/21 (quarterly instead of annual); therefore no annual MDS completed for the resident within 12 months of the last comprehensive MDS.
11. Record review of Resident #129's MDS records showed:
- admitted to the facility on [DATE];
- Significant change MDS completed on 11/28/20;
- An incomplete annual MDS dated [DATE];
- The facility did not fully complete an annual MDS for the resident within 12 months of the last comprehensive MDS.
12. Record review of Resident #130's MDS records showed:
- admitted to the facility on [DATE];
- No admission MDS completed.
- The facility did not complete an admission MDS within 14 days of the resident's admission date.
13. During an interview on 12/7/21 at 3:27 P.M., the Infection Preventionist and the Director of Operations said the previous MDS Coordinator gave his/her resignation and they have another nurse working on MDSs two days a week. They are currently in transition and do not have a MDS Coordinator and the MDS assessments haven't been completed and/or transmitted in the appropriate timeframe.
During an interview on 12/9/21 at 11:57 A.M., the Director of Nursing and the Administrator said they would expect MDS assessments to be completed accurately, timely, and submitted on time.
14. The facility did not provide a policy on completing comprehensive MDS assessments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had complete, accurate and individua...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of each resident. This affected 15 residents (Resident #4, #7, #8, #12, #25, #31, #33, #36, #42, #49, #52, #76, #78, #129, and #334) out of 20 sampled residents. The facility's census was 81.
1. Record review of the facility's policy titled, The Estates, regarding care plans, dated 7/20, showed:
- A care plan shall be used in developing the residents daily care routine and will be available to staff for review to ensure the best person-centered care is provided to our residents;
- Care plan will reflect a problem, goal, and approaches defined as the desired outcome for a specific resident problem;
- When goals and objectives are not achieved the care plan will be updated and modified accordingly;
- Care plan will be accessible to staff for review at any time;
- Care plan will be reviewed quarterly and updated as needed;
2. Record review of Resident #4's medical record showed:
- An admission date of 9/17/20;
- Diagnoses included long term (current) use of anticoagulants (blood thinning medications), benign prostatic hyperplasia (BPH: enlargement of the prostate causing difficulty in urination) with lower urinary tract symptoms, hypokalemia (decreased blood level of potassium), congestive heart failure (CHF: an inability of the heart to pump sufficient blood flow to meet the body's needs), retention of urine, and urinary tract infection (UTI);
- Physician's Order Sheet (POS), dated 12/1/21, with an order dated 6/16/21 for Eliquis (blood thinner) 2.5 milligrams (mg) twice daily related to long term (current) use of anticoagulants;
Review of the resident's comprehensive care plan, last revised 10/19/21, did not address anticoagulant use.
3. Record review of Resident #7's medical record showed:
- An admission date of 06/25/2019 and re-admission of 11/20/21;
- Diagnoses included generalized anxiety disorder (a feeling of worry, nervousness, or unease), Crohn's disease (chronic inflammatory bowel disease that affects the lining of the digestive tract), colostomy (a surgical opening into the intestines for bowel elimination), insomnia (difficulty sleeping), major depressive disorder (long-term loss of pleasure or interest in life), bipolar disorder (a mental disorder with periods of elevated moods and depression) and paranoid schizophrenia (a long-term mental disorder that affects a person's ability to think, feel or behave clearly).
Record review of the resident's quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 5/25/21, showed:
- Received as needed (PRN) pain medications;
- Received daily antipsychotic (mood stabilizers to treat severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and anti-anxiety medications;
- An Incomplete Annual MDS, dated [DATE], and incomplete quarterly MDS, dated [DATE].
Record review of the resident's POS, dated 12/01/21, showed:
- Acetaminophen (treats minor aches and pains) 325 mg by mouth as needed for pain, take 2 tablets nightly as needed for pain;
- Haloperidol (antipsychotic medication) 10 mg, 1 tablet by mouth at bedtime;
- Lorazepam (anti-anxiety medication) 1 mg, 1 tablet by mouth three times daily;
- Valproate Sodium Solution (anticonvulsant and used to treat bipolar disorder) 250 mg/milliliters (ml) give 10 ml by mouth two times daily.
Record review of the resident's comprehensive care plan, dated 4/13/21, updated on 7/05/21, and in use during the survey, showed no individualized interventions for pain, PRN pain medications, anti-anxiety medications, and antipsychotic medications.
4. Review of Resident #8's medical record showed:
- An admission date of 5/13/21;
- Diagnoses included mental disorder due to known physiological condition, sequelae of cerebral infarction (residual effects of a stroke), major depressive disorder, unspecified convulsions (uncontrollable muscle contractions), and insomnia.
Record review of the resident's admission MDS, dated [DATE], showed:
- Supervision for bed mobility, ambulation, and transfers;
- Minimal assistance of one staff member for dressing, toileting, and bathing;
- Extensive assistance of one staff member for personal hygiene;
- Occasionally incontinent of bowel and bladder;
- Totally dependent on staff for eating;
- Received daily anti-anxiety and antipsychotic medications.
Record review of the resident's POS, dated 12/01/21, showed:
- Acetaminophen 500 mg, 1 tablet by way of (via) gastrostomy (G-tube: a tube inserted through the belly which brings nutrition/medications directly to the stomach) every 6 hours PRN;
- Levetiracetam (anticonvulsant medication to treat seizures) 750 mg, 1 tablet via G-tube two times daily;
- Fluoxetine HCL (treats depression) 10 mg, 1 tablet via G-tube daily;
- Olanzapine (antipsychotic medication) 15 mg, 1 tablet via G-tube at bedtime;
- Trazodone (antidepressant medication) 150 mg, ½ tablet via G-tube at bedtime daily.
Record review of the resident's care plan, dated 7/16/21 and in use during the survey, showed no individualized interventions for bed mobility, ambulation, locomotion, toileting, personal hygiene, transfers, dressing, bathing, incontinence of bowel and bladder, convulsions, pain, PRN pain medications, anti-anxiety, anticonvulsant and antipsychotic medications.
5. Review of Resident #12's medical record showed:
- An admission date of 2/23/21;
- Diagnoses included pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
Record review of the resident's admission MDS, dated [DATE], showed:
- The brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 15 out of 15 which indicated the resident to be cognitively intact;
- Section F indicated activities and choices to be very important or somewhat important in each area, section F to not be completed in subsequent quarterly MDS dated [DATE];
- Section O 0100 C indicated yes for oxygen use while a resident, section O to not be completed in subsequent quarterly MDS dated [DATE] MDS.
Record review of the resident's quarterly MDS, dated [DATE], showed Section G0600 C indicated the resident to use a wheelchair for mobility.
Record review of the resident's POS, dated 12/1/21, showed:
- An order, dated 11/16/21, self catheterrization (insertion of a tube into the bladder to drain urine) two times daily;
- An order, dated 4/22/21 to check oxygen saturation every shift.
Record review of the resident's nurse progress note, dated 10/1/21, showed the resident fell, bruising noted, small knot on the top of his/her head.
Observation on 12/2/21 at 9:25 A.M. showed the resident wore a nasal cannula with supplemental oxygen, set at three liters.
Record review of the resident's comprehensive care plan, last updated 9/29/21, showed:
- No care plan for activities;
- No care plan for oxygen use;
- No care plan for mobility or falls;
- No care plan for intermittent catheterrization.
6. Review of Resident #25's medical record showed:
- An admission date of 6/23/21;
- Diagnoses included bipolar disorder, borderline personality disorder (mental disorder characterized by unstable moods, behavior and relationships), and anxiety disorder.
Record review of the resident's admission MDS, dated [DATE], showed:
- Supervision off and on the unit;
- Received daily antianxiety medication.
Record review of the resident's POS, dated 12/01/21, showed:
- Ativan (medication for anxiety) 0.5 mg, 1 tablet by mouth PRN for anxiety twice daily;
- Buspirone Hydrochloric acid (HCL) (medication for anxiety) 15 mg, 1 tablet by mouth three times a day;
- Haloperidol Lactate Solution (antipsychotic) inject 5 mg, intramuscularly every 6 hours PRN for severe agitation;
- Hydroxyzine HCL (used for allergies, itching, and anxiety) 25 mg, by mouth every 4 hours PRN for anxiety;
- Ibuprofen (mild pain medication and fever reducer) 600 mg, 1 tablet every 6 hours PRN for pain/fever;
- Topiramate (anticonvulsant; used for bipolar) 25 mg, 1 tablet by mouth two times daily;
- Tylenol 500 mg 2 tablets by mouth every 4 hours PRN for pain/fever;
- Valacyclovir HCL (antiviral) 600 mg 1 tablet by mouth daily for herpes (a virus causing contagious sores, most often around the mouth or on the genitals).
Record review of the resident's care plan, dated 07/12/21 and in use during the survey, showed no individualized interventions for pain, PRN pain medications, anxiety medications, bipolar disorder, borderline personality disorder, anxiety disorder, anxiety medications, antiviral medications, and antipsychotic medications.
7. Review of Resident #31's medical record showed:
- An admission date of 12/10/18 and re-admission date of 9/13/21;
- Diagnoses included insomnia, anxiety disorder, COPD, ataxia (unsteady gait), hypertension (high blood pressure), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations or states of awareness), psychosis (a mental disorder with a severe loss of contact with reality), chronic pain and schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions).
Record review of Resident #31's quarterly MDS, dated [DATE], showed:
- Supervision for dressing, mobility and transfers;
- Limited assistance with one staff for toileting, personal hygiene, and bathing;
- Occasionally incontinent of bladder, continent of bowel;
- Utilizes a wheelchair;
- Received daily antipsychotic and diuretic medications.
Record review of the resident's POS, dated 12/01/21, showed:
- Buspirone HCL 10 mg, 1 tablet by mouth twice daily for anxiety;
- Divalproex (anticonvulsant; used for bipolar) 500 mg, 1 tablet by mouth three times daily;
- Furosemide (diuretic) 40 mg, 2 tablets by mouth daily;
- Gabapentin (anticonvulsant; used for nerve pain and anxiety) 300 mg, 1 capsule by mouth three times daily;
- Levetiracetam 500 mg, 1 tablet by mouth two times daily;
- Medroxyprogesterone (hormone) 10 mg, 1 tablet by mouth two times daily for sexual dysfunction;
- Naproxen (pain reliever) 500 mg, 1 tablet by mouth two times daily for chronic pain;
- Olanzapine 20 mg, 1 tablet by mouth daily;
- Seroquel (antipsychotic medications) 400 mg, by mouth two times daily for schizophrenia;
- Spiriva (bronchodilator) 18 micrograms (mcg) CP-Handihaler, 1 capsule inhale orally one time daily for COPD;
- Symbicort 160-4.5 mcg Inhaler (bronchodilator) 2 puffs orally two times daily for COPD;
- Tylenol 325 mg, 2 tablets by mouth every 4 hours as needed for pain/fever;
- Albuterol AER HFA (bronchodilator) 1 inhalation orally every 4 hours PRN for shortness of breath;
- Amlodipine (antihypertensive) 2.5 mg, 2 tablets by mouth daily for hypertension;
- Propranolol (antihypertensive) 20 mg, 1 tablet by mouth three times daily for hypertension.
Record review of the resident's care plan, dated 9/08/20 and updated 7/05/21 and in use during the survey, showed no individualized interventions for bed mobility, ambulation, locomotion, toileting, personal hygiene, transfers, dressing, bathing, occasional bladder incontinence, chronic pain, pain medications, hypertension, antihypertensives, COPD, bronchodilator medications, antipsychotic medications, diuretic medications, seizures, anticonvulsant medications, anxiety disorder, antianxiety medications, psychosis, schizoaffective disorder and sexually inappropriate behaviors on hormone therapy.
8. Record review of Resident #33's medical record showed:
- An original admission date of 4/22/19 with re-admission date of 11/12/21;
- Diagnoses included chronic pain, Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), COPD, transient cerebral ischemic attack (TIA: a neurologic deficit that produces stroke symptoms that resolve within 24 hours), atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries causing obstruction of blood flow), and mood disorder (a condition which causes a person's emotional state to be distorted and interferes with the ability to function);
- Falls occurred on 7/28/21, 8/9/21, 8/30/21, 9/15/21, 9/25/21, 9/29/21, 10/14/21, and 10/31/21;
- The POS, dated 12/1/21, showed an order, dated 11/12/21, to assess and monitor resident for pain four times daily with med pass, an order, dated 11/12/21 for acetaminophen 650 mg every four hours PRN for fever or pain, an order, dated 11/12/21, for Gabapentin (an anticonvulsant medication; also used for pain) 300 mg three times daily for neuropathy (a disease of the nerves causing tingling, burning or loss of sensation), and an order, dated 11/13/21, for Percocet (pain medication) 5-325 mg every six hours PRN for pain.
Record review of the resident's comprehensive care plan on 11/30/21 at 10:51 A.M. showed no plan of care for falls or pain. The care plan did not address any falls including a fall on 11/13/21. Further record review of the resident's care plan on 12/1/21, showed the facility added an update for 11/30/21 to reflect a fall on 11/13/21 in which the resident fell while transferring self and suffered a fractured fibula (did not specify right or left).
9. Record review of Resident #36's medical record showed:
- An original admission date of 12/23/19 with readmission date of 3/24/21,
- Diagnoses of dementia (disorder marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) with behavioral disturbance, major depressive disorder (long-term loss of pleasure or interest in life), chronic pain (pain that is ongoing and usually lasts longer than six months), hypertension (high blood pressure), and Type 2 diabetes mellitus.
Observation on 12/1/21 at 2:59 P.M. showed the resident lay in bed on a wet incontinent pad. The resident had excoriation on the left buttock approximately six centimeters (cm) by two cm, and on the right buttock approximately three cm by two cm, with no open areas.
Record review of the resident's progress note, dated 10/18/21 at 12:00 P.M. showed resident has approximately six cm by two cm red excoriation to his/her left buttock and approximately three cm by two cm on the right buttock. Staff documented the Nurse Practitioner was notified.
Record review of the resident's Treatment Administration Records (TARs) showed:
- On the 10/1/21 - 10/31/21 TAR, an order, dated 10/18/21, for Triad Hydrophilic wound dress paste: apply to buttocks topically twice daily until healed, discontinued on 11/18/21;
- On the 11/1/21 - 11/30/21 TAR, an order, dated 11/18/21, apply Lotrisone and Bactroban cream to bilateral buttocks with every incontinent episode until healed.
Record review of the resident's comprehensive care plan, last revised 7/19/21, showed no plan of care for incontinence or skin breakdown.
10. Record review of Resident #42's medical record showed:
- An original admission date of 6/7/21 with readmission date of 11/12/21;
- Diagnoses included unspecified heart failure (an inability of the heart to pump sufficient blood flow to meet the body's needs), COPD, bipolar disorder (a mental disorder that causes unusual shifts in mood), Type 2 diabetes mellitus with chronic kidney disease, urinary incontinence, generalized anxiety disorder (persistent worry and fear about everyday situations), major depressive disorder (long-term loss of pleasure or interest in life), cerebral infarction (stroke, damage to the brain from interrupted blood supply), muscle weakness, and difficulty in walking;
- POS, dated 12/2/21, with an order, dated 9/8/21, for Eliquis (an anticoagulant medication) five mg twice daily related to heart failure;
-Comprehensive care plan, last revised 10/5/21, did not address anticoagulant use, dietary needs, urinary incontinence, or ADLs.
11. Record review of Resident #49's medical record showed:
- An admission date of 10/14/17;
- A diagnosis of urinary tract infection (an infection of the urinary system);
- hospitalized [DATE] - 11/29/21.
Record review of the resident's hospital medical record showed:
- admitted to the hospital on [DATE] - 11/29/21;
- A diagnosis of UTI;
- Received antibiotic (a medication that destroys or slows down the growth of bacteria) treatment for the UTI while hospitalized .
Record review of the resident's care plan, last revised on 11/29/21, showed:
- Did not address the resident's UTI;
- The facility failed to address the resident's UTI on the care plan.
12. Record review of Resident #52's medical record showed:
- admission date of 1/31/19;
- Diagnoses include dementia (disorder marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning), and chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs);
- The quarterly MDS, dated [DATE], showed the BIMS score to be 10 out of 15 which indicated the resident to be severely cognitively impaired.
Record review of the POS, dated 12/2/21, showed:
- An order, dated 8/24/21, to admit to hospice (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life).
- An order, dated 9/30/21, to cleanse coccyx with soap and water, pat dry, apply calmoseptine (a moisture barrier that protects and helps heal skin irritations) every shift for wound prophylaxis;
- An order, dated 8/24/21, for quetiapine fumarate (an antipsychotic medication used to treat certain mental/mood conditions such as schizophrenia, bipolar disorder, sudden episodes of mania or depression) 25 milligrams (mg) one time a day;
- An order, dated 8/24/21, for Olanzapine (an antipsychotic medication that is used to treat psychotic conditions such as schizophrenia and bipolar disorder)
Record review of the comprehensive care plan, last updated 7/13/21, showed:
- No care plan for hospice or end of life care;
- No care plan for skin or wound care;
- No care plan for antipsychotic medications.
13. Record review of Resident #76's medical record showed:
- An admission date of 4/8/19;
- Diagnoses included venous insufficiency (difficulty with blood returning to the heart from the legs), depressive disorder, and chronic pain (pain that is ongoing and usually lasts longer than six months);
- The quarterly MDS, dated [DATE], showed the BIMS, score to be 10 out of 15 indicated the resident to be moderately cognitively impaired.
Record review of the POS, dated 12/1/21, showed:
- An order, dated 5/14/19, for acetaminophen 325 mg, two tablets every six hours as needed for pain;
- An order, dated 9/18/20, for tramadol HCl (a medication used to treat moderate pain) 50 mg, give one tablet one time a day for general complaints of pain related to chronic pain;
- An order, dated 9/22/20, for acetaminophen 650 mg, give one tablet three times a day for chronic pain.
Record review of the comprehensive care plan, last updated 7/5/21 showed no care plan for pain management.
14. Record review of Resident #78's medical record showed:
- An admission date of 12/18/20 and readmission date of 9/01/21;
- Diagnoses included Alzheimer's disease (progressive mental deterioration), hypertension, heart failure (condition in which the heart does not pump blood as well as it should) and psychosis.
Record review of the Resident #78's Medicare 5 day MDS, dated [DATE], showed:
- Extensive assistance of one staff for bed mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Occasionally incontinent of bowel and bladder;
- Received daily antipsychotic, diuretic and antidepressant medications.
Record review of Resident #78's POS, in use during the survey, showed:
- Acetaminophen suppository 650 mg 1 suppository rectally every 6 hours as needed for pain/headache;
- Amlodipine Besylate (antihypertensive) 10 mg 1 tablet by mouth daily for hypertension;
- Aspirin 81 mg 1 tablet by mouth daily for clot prevention;
- Carvediolol (antihypertensive) 6.25 mg 1 tablet by mouth two times a day for high blood pressure;
- Cilostazol (vasodilator for blood flow to legs) 50 mg 1 tablet by mouth two times daily;
- Hydralazine HCL 25 mg 1 tablet by mouth daily for hypertension;
- Isosorbide Mononitrate Extended Release 60 mg 1 tablet by mouth daily for hypertension;
- Lasix 20 mg 1 tablet by mouth one time a day every other day;
- Mirtazapine (antidepressant) 15 mg ½ tablet by mouth one time daily;
- Olanzapine 10 mg 1 tablet by mouth one time daily;
- Oxcarbazepine (anticonvulsant used for psychosis) 150 mg 1 tablet by mouth one time daily.
Record review of the resident's care plan, dated 01/22/21 and updated 11/05/21 and in use during the survey, showed no individualized interventions for bed mobility, dressing, eating, toileting, transfers, personal hygiene, bathing, locomotion, incontinence, Alzheimer's dementia, hypertension, heart failure, antihypertensive medications, diuretics, antidepressant medications, antipsychotic medications, pain and PRN pain medications.
15. Record review of Resident #129's medical record showed:
- An admission date of 11/28/20;
- Diagnoses included COPD;
Record review of the resident's POS, dated November and December 2021, showed an order dated 8/24/21, to administer oxygen at 2 liters per nasal cannula (a tube delivering oxygen to a person's nose) PRN;
Record review of Resident #129's Comprehensive care plan, dated 9/9/21, showed oxygen use not addressed with specific interventions and/or goals.
Observations on 11/29/21 at 2:12 P.M., on 11/30/21 at 3:22 P.M., on 12/1/21 at 1:30 P.M. and on 12/2/21 at 10:00 A.M., and 2:00 P.M., showed the resident with oxygen infused at 2 liters per nasal cannula per oxygen concentrator (a device that converts room air to pure oxygen).
16. Record review of Resident #334's medical record showed:
- An admission date of 4/26/19;
- Diagnoses included bipolar disorder, Alzheimer's disease, major depressive disorder-recurrent, and chronic kidney disease (a gradual loss of kidney function);
Record review of the annual MDS, dated [DATE], showed:
- An incomplete BIMS assessment;
- Extensive assistance for mobility, dressing, eating and toileting;
- Totally dependent on one staff for transfers, personal hygiene and bathing;
- Frequently incontinent of bowel and bladder.
Record review of the POS, dated 12/1/21, showed:
- An order, dated 9/23/21, for mupirocin ointment 2% (a medication used to treat skin infections), apply to right posterior wounds topically every day shift for wound care, right shoulder proximal and distal wounds, clean with wound cleanser, apply bactroban, (a prescription medicine used to treat skin infections), alginate (a strong, versatile, and natural wound care dressing) to cover only wound bed, cover with kiralite cool bordered dressing (a debriding, moisturizing dressing that provides an ideal environment for wounds);
- An order dated 10/18/21 for triad hydrophilic wound dress paste (a zinc oxide-based hydrophilic paste that absorbs moderate levels of wound moisture), apply to buttocks topically as needed for wound care.
Observation on 11/30/21 at 10:37 A.M., showed the top of the resident's head and three-quarters of the way down his/her forehead, to be scabbed and to have open places on top of the scalp. Observation showed one Band-Aid with adhesive in place on the wound, covering one area on the top of the resident's head.
Record review of the comprehensive care plan, last updated 8/27/21, showed no care plan for skin care or pressure ulcers.
17. During an interview on 12/8/21 at 2:16 P.M., Registered Nurse (RN) F said it is the MDS Coordinator's responsibility to update the care plans. The nurses let the MDS Coordinator know of any updates or changes so the care plan can be updated.
During an interview on 12/9/21 at 11:57 A.M., the Director of Nursing and Administrator said they would expect comprehensive care plans to assess all areas of concern. The MDS coordinator is responsible for the care plans.
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 interview and record review, the facility failed to update and revise care plans with specific interventions to meet in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs in a timely manner for four residents (Resident #29, #33, #36, and #52) out of 20 sampled residents and failed to allow residents and/or representatives of the resident the opportunity to participate in his/her care plan meetings for four residents (Resident #12, #49, and #52) out of 20 sampled residents and one resident (#57) outside the sample. The facility's census was 81.
1. Record review of the facility's policy titled The Estates, related to care plans, dated 7/20, showed:
- A care plan shall be used in developing the resident's daily care routine and will be available to staff for review to ensure the best person-centered care will be provided to our residents;
- The care plan will reflect a problem, goal, and approaches defined as the desired outcome for a specific resident problem;
- When goals and objectives are not achieved, the resident's medical record will be updated and the care plan will be modified accordingly;
- The care plan will be accessible to staff for review at any time;
- The care plan will be reviewed quarterly and updated as needed;
- Care plan meetings will be held quarterly with the interdisciplinary team, the resident, and the responsible party or the guardian.
2. Record review of Resident #12's medical record showed:
- An admission date of 2/23/21;
- Diagnoses included pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart does not pump blood as well as it should);
- The admission Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 3/6/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 15 out of 15 which indicated the resident to be cognitively intact.
Record review of the resident's comprehensive care plan, last revised on 9/29/21, showed:
- No documentation that the resident attended a care plan meeting.
- No documentation that staff invited the resident to a care plan meeting.
During an interview on 11/30/21 at 9:43 A.M., Resident #12 said the staff do not ask what he/she might want. He/She has never seen any paperwork and never been asked to attend a care plan meeting.
3. Record review of Resident #29's medical record showed:
- An admission date of 9/26/20, and readmission date of 11/8/21;
- Diagnoses included major depression, anxiety disorder, urinary retention (inability to empty the bladder of urine), schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions (false beliefs), and hallucinations (an experience involving the apparent perception of something not present).
Record review of Resident #29's quarterly MDS, dated [DATE], showed:
- Alert and oriented;
- Verbal behaviors directed towards other occurred 1 to 3 days a week;
- Required limited to extensive assistance from staff with Activities of Daily Living (ADLs);
- Indwelling urinary catheter (a tube inserted into the bladder to drain urine).
Record review of the resident's nurse's note/progress note, dated 10/25/21 at 7:30 A.M., showed the resident called 911 (emergency number) and told the emergency personnel he/she was suicidal (deeply unhappy or depressed, likely to commit suicide) with a plan and was in pain. The resident verbalized he/she would rip his/her catheter out and choke him/her self with the catheter. EMS transported the resident to the hospital for an evaluation.
Record review of the resident's care plan, dated 9/9/21 with revision dated 12/1/21, showed:
- The resident's threat of suicidal ideations made on 10/25/21 were not addressed in the care plan until 12/1/21.
During an interview on 12/9/21 at 11:55 A.M., the Director of Operations said she expected the resident's suicidal ideations to be addressed in a timely manner with specific approaches/goals after the resident was sent out to the hospital for his/her suicidal ideations on 10/25/21. She said the MDS Coordinator is responsible to update, revise, and review the resident's care plan to address specific care needs of the resident.
4. Record review of Resident #33's medical record showed:
- An original admission date of 4/22/19 with readmission date of 11/12/21;
- Diagnoses included chronic pain, major depressive disorder, Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), COPD, transient cerebral ischemic attack (TIA: a neurologic deficit that produces stroke symptoms that resolve within 24 hours), atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries causing obstruction of blood flow), and mood disorder (a condition which causes a person's emotional state to be distorted and interferes with the ability to function).
Record review of the resident's progress notes showed:
- On 11/4/21 at 4:12 P.M., the resident reported to another nurse that he/she never gets pain medicine and has been in pain and wanted to commit suicide. Facility staff sent the resident to the Emergency Department for assessment of pain. The resident returned and was sent to another hospital for psychiatric evaluation due to his/her suicidal ideations;
- No social service notes following up on the resident's hospital stay for suicidal ideation.
Record review of the resident's comprehensive care plan, last revised 11/30/21, showed no update or interventions to reflect the resident's suicidal ideation.
5. Record review of Resident #36's medical record showed:
- An original admission date of 12/23/19 with readmission date of 3/24/21;
- Diagnoses of dementia (disorder marked by memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) with behavioral disturbance, major depressive disorder (long-term loss of pleasure or interest in life), chronic pain (pain that is ongoing and usually lasts longer than six months), hypertension (high blood pressure), and Type 2 diabetes mellitus .
Record review of the resident's progress note, dated 5/15/21 at 11:06 P.M., showed the resident experienced a fall.
Record review of the resident comprehensive care plan, last reviewed 7/19/21, showed staff did not update the care plan with interventions after the fall on 5/15/21.
6. Record review of Resident #49's medical record showed an admission date of 10/14/17.
Record review of the resident's care plan, last revised on 11/29/21, showed no documentation that the resident attended and/or was invited to attend his/her care plan meetings.
7. Record review of Resident #52's medical record showed:
- An admission date of 1/31/19;
- The resident has a designated responsible party (RP);
- Diagnoses include dementia and COPD;
- The quarterly MDS, dated [DATE], showed the BIMS score to be 10 out of 15 which indicated the resident to be moderately cognitively impaired.
Record review of the resident's POS, dated 12/2/21, showed an order, dated 9/3/21, for a pureed texture and nectar consistency diet.
Record review of the resident's comprehensive care plan, last updated 10/21/21, showed:
- The resident to be on a regular diet;
- The facility did not update the care plan for new diet orders;
- No documentation to show the resident was invited to attend and/or attended his/her care plan meetings.
8. Record review of Resident #57's medical record showed:
- admission date of 2/14/19;
- A guardianship document, dated 9/13/21, to show the resident's sister to be the RP;
- Diagnoses included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), and pain;
- The quarterly MDS, dated [DATE], showed the BIMS score to be 14 out of 15 indicating the resident to be cognitively intact.
Record review of the comprehensive care plan, last updated 10/21/21 showed no documentation that the resident and/or his RP attended and/or were invited to attend a care plan meeting.
During an interview on 12/01/21 at 9:48 A.M., the Social Worker (SW) said the resident's family member is his/her guardian.
During an interview on 12/01/21 at 1:18 P.M., the RP said there is no communication with the nursing home at all, they will not call him/her back or come to the phone, and he/she is not invited to any meetings.
9. During an interview on 12/9/21 at 11:57 A.M., the Administrator said she would expect a resident's comprehensive care plan to be updated, along with new interventions, when there has been a change in their care requirements. The MDS Coordinator is responsible for updating the care plans. She would expect the residents and/or the responsible party to be allowed to participate in the resident's care plan meetings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in a sufficient detail to enable an accurate reconcil...
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Based on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in a sufficient detail to enable an accurate reconciliation of the controlled drugs to ensure the nursing staff signed at the beginning/end of each shift. The facility failed to document the total number of narcotic drug cards counted for four of four narcotic count books checked. The facility's census was 81.
1. Record review of the facility's policy titled, Controlled Substance Administration and Accountability Policy/Procedure, dated January 2020, showed:
- It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances and wasting of medications;
- Procedures:
- All controlled substances are recorded on the designated usage form. Controlled drug record serves the dual purpose of recording both narcotic disposition and patient administration;
- Controlled substance count is done at the beginning and end of every shift and signed off by approved personnel.
2. Record review of the Certified Medication Technician (CMT) narcotic count sheet on the back half of the Memory Care Unit (MCU), dated 12/1/21 through 12/7/21, showed:
- No signature and/or initials by the on-coming CMT, a total of 19 shifts during a 7 day look behind;
- No signature and/or initials by the off-going CMT, a total of 18 shifts during a 7 day look behind;
- Total narcotic drug cards not documented as counted, a total of 15 shifts during a 7 day look behind.
3. Record review of the CMT narcotic count sheet, dated 10/24/21 through 12/7/21, on the B Wing Hall, showed:
- No signature and/or initials by the on-coming CMT, a total of 96 shifts;
- No signature and/or initials by the off-going CMT, a total of 96 shifts;
- No total number of drug cards documented as counted from 10/24/21 through 12/7/21.
4. Record review of the A Wing Nurse's narcotic count sheet, dated 11/20/21 through 12/6/21, showed:
- No signature and/or initials by the on-coming nurse, a total of eight shifts;
- No signature and/or initials by the off-going nurse, a total of nine shifts;
- No total number of drug cards documented as counted from 11/20/21 through 12/6/21.
5. Record review of the B Wing Nurse's narcotic count sheet, dated 11/1/21 through 11/19/21, showed:
- No signature and/or initials by the on-coming nurse, a total of 18 shifts;
- No signature and/or initials by the off-going nurse, a total of 18 shifts;
- No total number of drug cards documented as counted from 11/1/21 through 11/19/21.
6. During an interview on 12/7/21 at 4:08 P.M., the Director of Operations verified the licensed nursing staff worked 12 hour shifts and non-licensed nursing staff, CMTs worked eight hour shifts. She expected the licensed and non-licensed nursing staff to count narcotics at the beginning and end of each shift with the on-coming and off-going nursing staff. The nursing staff should count each narcotic drug card and document the amount of drug cards counted on the narcotic count sheet for an accurate, narcotic reconciliation record. She verified the narcotic count sheets were not accurate for a complete reconciliation of controlled substances. The Director of Operations said it was the Director of Nursing (DON) and/or designee's responsibility to monitor the narcotic count sheets daily for accuracy. She expected all nursing staff to follow the facility's policy regarding counting narcotics.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure sufficient dietary staff was available to effectively carry out the functions of the food and nutrition services, incl...
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Based on observation, interview, and record review, the facility failed to ensure sufficient dietary staff was available to effectively carry out the functions of the food and nutrition services, including preparing and serving meals, in the scheduled time frames. This had the potential to affect all residents. The facility's census was 81.
Record review of the facility's undated Meal Times showed:
- Breakfast served at 7:00 A.M.;
- Lunch served at 12:00 P.M.;
- Dinner served at 5:00 P.M.
Observation on 11/29/21 of the lunch meal service showed:
- At 12:04 P.M., six residents sat at tables in the main dining room waiting for the lunch meal to be served;
- At 12:40 P.M., the lunch meal had still not been served in the main dining room or hallways;
- At 1:22 P.M., the lunch meal served on regular plates with plastic silverware and dessert in foam hinged containers;
- At 2:05 P.M., residents went into the dining room and asked about a birthday party activity scheduled to start at 2:00 P.M.;
- At 2:18 P.M., staff delivered the last hall cart;
- At 2:20 P.M., staff announced overhead the birthday party activity would be postponed until 2:30 PM.
During an interview on 12/1/21 at 9:03 A.M., the Dietary Manager (DM) said until more staff can be hired and the dietary department is staffed enough to have time to go gather the dirty dishes and wash them, the meals will be served on foam dishware with plastic silverware. On 11/29/21 the kitchen ran out of foam plates and had to use regular.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at appetizing temperatures for five residents (Residents #12, #25, #74, and #76) out of 20...
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Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at appetizing temperatures for five residents (Residents #12, #25, #74, and #76) out of 20 sampled residents and one resident (#17) outside the sample. This practice potentially affected all residents in the facility. The facility's census was 81.
Record review of the facility's undated policy titled, Kitchen Sanitation Checklist showed hot food leaves the kitchen above 140 degrees Fahrenheit (F).
Record review of the facility's menu for the lunch meal on 11/29/21 showed:
- Bacon wrapped pork fillet with raspberry sauce;
- Baked sweet potato;
- Seasonal vegetable;
- Pound cake with brown sugar peaches.
Record review of the food temperature logs showed:
- No temperature logs prior to 11/22/21;
- No temperatures recorded for breakfast and lunch meals 11/24/21 through 11/26/21;
- No temperatures for lunch and evening meal on 11/29/21.
During an interview on 11/29/21 at 11:03 A.M., the dietary manager (DM) said she did not know that food temperatures were supposed to be checked and recorded until 11/22/21. She started temperature logs but temperatures are still not being taken and recorded like they should be.
Observation on 11/29/21 at 2:04 P.M., showed Resident #17's lunch meal included pork tenderloin, cooked broccoli and a baked sweet potato. The resident could not cut the pork tenderloin and the broccoli had a pale, watery appearance.
During an interview on 11/29/21 at 2:04 P.M., Resident #17 said the pork could not be cut and the broccoli was too hard to eat. Resident #17 said he/she is unable to eat the meal.
Record review of the facility's menu for the lunch meal on 11/30/21 showed:
- Open face hot beef sandwich;
- Mashed potatoes;
- Beef gravy;
- Honey buttered corn;
- Cherry pie crisp.
Observation of the meal service in the kitchen on 11/30/21 showed:
- At 1:05 P.M., dietary staff placed residents' lunch trays on an open hall cart, uncovered;
- At 1:16 P.M., dietary staff placed covers on the plates and sent the uncovered cart out for delivery to the residents;
- At 1:20 P.M.,, dietary staff placed residents' lunch trays on an open hall cart, uncovered;
- At 1:22 P.M., food temperatures were taken with a digital stem thermometer from a test tray. The beef patty 115.5 degrees F, orzo (substituted for mashed potatoes) 124.5 degrees F, and corn 142.3 F;
- At 1:35 P.M., dietary staff placed covers on the plates and sent the uncovered cart out to 200 hall for delivery to the residents.
Record review of Resident #12's medical record showed:
- An admission date of 2/23/21;
- Diagnoses included pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
During an interview on 11/30/21 at 9:46 A.M., the resident said the food is not good, it is never hot and it looks terrible.
Record review of Resident #25's medical record showed:
- An admission date of 6/23/21;
- Diagnoses included bipolar disorder, borderline personality disorder (mental disorder characterized by unstable moods, behavior and relationships), and anxiety disorder.
During an interview on 11/29/21 at 10:50 A.M., Resident #25 said he/she received three meals a day and snacks. Resident #25 said the food does not always taste good and could be better. The temperature of the food is always cold. Food that should be cold is not always as cold as it should be.
Record review of Resident #74's medical record showed:
- An admission date of 3/23/21;
- Diagnoses included major depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) and schizophrenia (a long term mental disorder that affects a person's ability to think, feel or behave clearly, sometimes including delusions (false beliefs or altered reality) and hallucinations (a sensory experience of something that does not exist outside of the mind).
During an interview on 11/29/21 at 12:48 P.M., the resident said he/she received three meals a day and generally the food is not good and served cold.
Record review of Resident #76's medical record showed:
- An admission date of 4/8/19;
- Diagnoses include venous insufficiency (difficulty with blood returning to the heart from the legs), depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic pain (pain that is ongoing and usually lasts longer than six months).
During observation and interview on 11/30/21 at 8:37 AM the resident sat in a wheelchair at the side of his/her bed with a bedside table in front of him/her. A breakfast plate with two pancakes topped with something that looked like chocolate pudding on the plate, a bowl of oatmeal, and bread crust sat on the table. The resident said the breakfast was not good, it was cold, and he/she could not eat it.
During an interview on 12/09/21 at 11:57 A.M., the Administrator said she would expect food to be served at acceptable temperature levels with a pleasant and palatable presentation. Food temperatures should be taken at each meal.
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 infection control practices to prevent the d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for five residents (Residents #12, #36, #52, #42, #129, and #334) out of 20 sampled residents when the facility staff did not wash hands and change gloves from dirty to clean. The facility staff failed to address supplemental oxygen tubing which lay on the floor and failed to clean contaminated/soiled resident-use items. The facility staff failed to provide a safe environment to prevent the development and transmission of infection for two residents (Resident #26 and #46) outside the sample when the staff used a multiple-use blood glucometer (a device used to measure blood sugar) without proper sanitation. The facility staff failed to clean and sanitize multi-use equipment before and after each use for one resident (Resident #36) out of the 20 sampled residents. The facility staff failed to perform annual tuberculosis (TB: a potentially serious infectious disease that mainly affects the lungs) screening for six residents (Residents #11, #29, #33, #49, #57 and #76) out of six sampled residents. The facility staff failed to ensure one resident (Resident #49) out of 20 sampled residents was free of communicable disease and met the criteria to come off isolation. The facility failed to fully implement Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) recommended infection control practices during a coronavirus disease 2019 (COVID-19: an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is highly transmissible via droplet/airborne transmission) pandemic when the facility failed to post signage at facility entrances alerting visitors of confirmed COVID-19 in the facility. The facility's census was 81.
1. Record review of the facility's undated policy titled, Glove and Hand Washing Policy, showed:
- All employees will use proper hand washing procedures and glove usage in accordance with state and federal sanitation guidelines;
- Gloves are changed any time hand washing would be required;
- Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again.
Record review of the facility's policy titled, Infection Control Guidelines: Standard Precautions Policy, dated 12/1/16, showed change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one).
2. Record review of Resident #36's medical record, showed:
- admission date of 3/24/21;
- Diagnosis included dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily living).
Observation on 12/1/21 at 2:59 P.M. showed Resident #36 lay in bed on a wet incontinent pad. Certified Nurse Aide (CNA) J wore gloves and provided incontinent care. CNA J did not sanitize or wash his/her hands or change gloves. With the same gloves, CNA J picked up a tube of barrier cream and applied barrier cream to the resident's peri area/buttocks. CNA C picked up the contaminated barrier cream tube and placed it in his/her pocket. CNA C carried the barrier cream in his/her pocket and left Resident #36's room and entered Resident #42's room.
During an interview on 12/7/21 at 3:05 P.M., CNA J said he/she should have washed his/her hands when he/she entered the room and then put gloves on.
3. Observation on 12/1/21 at 2:42 P.M. showed Resident #42 lay in bed on a wet incontinent pad. CNA C wore gloves, provided incontinent care and did not sanitize or wash his/her hands or change gloves. With the same gloves, CNA C pulled the barrier cream tube from his/her pocket. CNA C applied the barrier cream on the resident's peri area/buttocks.
During an interview on 12/7/21 at 3:04 P.M., CNA C said he/she should have washed his/her hands when he/she entered the room and then put gloves on.
4. Observation of Resident #52 on 12/2/21 at 2:30 P.M., showed:
- The Director of Nurses (DON) provided wound care for the resident and was assisted by the Assistant Director of Nurses (ADON);
- The DON wore gloves and removed the soiled dressing from the coccyx (a small triangular bone at the base of the spinal column to fuse the vertebrae);
- The DON did not remove the gloves and did not sanitize his/her hands;
- With the same gloves, the DON cleaned the coccyx wound, picked up the tube of calmoseptine (barrier/wound treatment) cream and applied calmoseptine cream to the resident's coccyx area.
During an interview on 12/8/21 at 8:56 A.M., the DON said she realized she did not change gloves prior to applying the calmoseptine and she should have.
5. Observation on 12/7/21 at 2:45 P.M. of Resident #334 showed:
- Licensed Practical Nurse (LPN) G provided wound care for Resident #334 and was assisted by CNA T and CNA C;
- LPN G obtained wound supplies from treatment cart and placed the items on bedside table without a barrier;
- LPN G obtained scissors from treatment cart, did not clean the scissors, and placed them on bedside table;
- LPN G filled a medicine cup with bactroban ointment (a prescription medicine used to treat skin infections);
- LPN G removed the resident's sandwich from the bedside table;
- LPN G wore gloves and adjusted the height and head of bed using the bed remote control;
- LPN G removed gloves, did not wash hands, and applied gloves;
- LPN G, pulled the bed sheet to turn the resident and held the resident on his/her left side;
- LPN G was unable to reach the wound on the left shoulder, removed gloves, did not wash hands, left the room to obtain wound cleanser, returned with CNA T and CNA C;
- CNA T and CNA C did not wash hands, applied gloves, and rolled the resident to his/her right side;
- LPN G wore gloves and removed the soiled dressing;
- With the same gloves, LPN G cleaned the wound to the left shoulder;
- LPN G did not remove gloves, did not wash hands, opened the package of bandage, did not clean the scissors, and cut the bandage to size;
- With the same gloves, LPN G applied bactroban ointment to the left shoulder wound, placed the soiled bandage over the wound;
- LPN G collected supplies from the table and discarded them.
During an interview on 12/7/21 at 3:00 P.M., LPN G said he/she should have cleaned the bedside table, should have cleaned the scissors before use, and should have washed his/her hands each time he/she changed gloves.
6. Record review of the facility policy titled Oxygen Supplies Policy, dated 12/1/18, showed:
- This facility will maintain oxygen device supplies in a clean status, ensuring proper labeling and replacement of supplies as needed per physician's orders;
- Oxygen supplies will be changed according to physician's order or tubing will be changed according to facility's standard practice: oxygen tubing will be changed one time per week if oxygen is in use, distilled water containers for oxygen concentrators are replaced, as needed, oxygen concentrator filters should be removed and cleaned weekly;
- Oxygen tubing changes will be documented on the associated TAR/MAR;
- If additional documentation is required according to physician's order this will be also added to the resident's TAR.
7. Record review of Resident #12's medical record showed:
- admission date of 2/23/21;
- Diagnoses include pain, kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
Observation on 11/30/21 at 10:13 A.M., showed the resident lay in bed. A nasal cannula (a tube delivering oxygen to a person's nose) attached to the supplemental oxygen flowmeter lay on the floor beside the bed. The supplemental oxygen tube showed it to be four tubes connected within each other and with one connection secured with green tape. The supplemental oxygen tube did not contain a date of when it was placed in use. The humidifier bottle (a medical device used to increase the moisture in supplemental oxygen to alleviate a sore, dry/bloody nose while using the supplemental oxygen) was 3/4 full of a clear liquid. The supplemental oxygen flowmeter set at three liters.
During an interview on 11/30/21 at 10:13 A.M., the resident said he/she uses oxygen sometimes. The resident needs a longer tube so he/she can move around the bed. The facility will not provide a longer tube so he/she saved shorter ones and cut the ends using toenail clippers then connected the tubes together. The resident said the facility does not change the tubing or fill the water bottle (the water bottle supplies humidification to the supplemental oxygen). The resident fills the water bottle with tap water.
Observation on 12/2/21 at 9:25 A.M., showed the resident wore a nasal cannula attached to the supplemental oxygen flowmeter and the flowmeter set at three liters. The supplemental oxygen tube showed it to be four tubes connected within each other and with one connection secured with green tape, undated.
During an interview on 12/2/21 at 9:25 A.M., the resident said the facility had not changed the tubing.
Observation on 12/7/21 at 9:40 A.M., showed the resident wore a nasal cannula attached to the supplemental oxygen flowmeter and the flowmeter set at three liters. The supplemental oxygen tube showed it to be four tubes connected within each other and with one connection secured with green tape, undated.
During an interview on 12/7/21 at 9:40 A.M., the resident said the facility had not changed the tubing.
Record review of the resident's medication administration record (MAR):
- Dated 10/1/21 - 10/31/21 showed no documentation of changing oxygen tubing;
- Dated 11/1/21 - 11/30/21 showed no documentation of changing oxygen tubing.
8. Record review of Resident #129's December 2021 physician order sheet (POS) showed an order dated 8/24/21, to administer oxygen at 2 liters per nasal cannula as needed (PRN).
Observations of the resident showed the following:
- On 11/29/21 at 2:13 P.M., the resident lay in the bed and did not have the supplemental oxygen in the resident's nose. An oxygen concentrator (a device that converts room air to pure oxygen) sat next to the resident's bed and the flowmeter indicated 2 liters of supplemental oxygen delivered. The resident's oxygen nasal cannula and oxygen tubing lay directly on the floor next to the oxygen concentrator;
- On 11/30/21 at 3:22 P.M., the resident lay in the bed and did not have the supplemental oxygen in the resident's nose. The resident's oxygen nasal cannula lay directly in the bed with oxygen tubing draped onto the floor next to the oxygen concentrator;
- On 12/1/12 at 1:30 P.M., the resident lay in the bed and did not have the supplemental oxygen in the resident's nose. The resident's oxygen nasal cannula lay directly on the floor with the oxygen tubing lay directly on the floor next to the oxygen concentrator;
- On 12/2/21 at 10:00 A.M. and 2:00 P.M., the resident sat in the wheelchair without the oxygen nasal cannula in his/her nose. The resident's oxygen nasal cannula and oxygen tubing lay directly on the floor next to the oxygen concentrator.
During an interview on 12/9/21 at 11:55 A.M., the Director of Operations said the resident's oxygen nasal cannula and oxygen tubing should not lay directly on the bed and/or on the floor due to infection control purposes. She said the oxygen nasal cannula should be positioned correctly in the resident's nares and oxygen tubing should be coiled/stored in a plastic bag.
9. Record review of the facility's policy titled Glucometer (device used to measure the amount of sugar in the blood) Disinfection, dated 1/11/19, showed:
- The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees;
- Equipment and Supplies: Disinfection wipes, glucometer, and gloves as indicated;
- Wash hands/use alcohol-based hand sanitizer;
- Explain procedure to the resident;
- Provide privacy;
- Put on gloves;
- Obtain capillary blood sampling;
- Remove gloves and wash hands or apply alcohol gel prior to exiting room or starting another resident's accucheck (blood glucose machine);
- Reapply gloves if there is visible contamination of the device or if the resident is human immunodeficiency virus (HIV) or Hepatitis B surface antigen (HBsAg) positive;
- Retrieve disinfection wipe from container;
- Cleanse the glucometer with the disinfection wipe, ensuring properly saturated. Leave wipe in contact with glucometer for length of time designated by manufacturer recommendations;
- Discard disinfectant wipe in waste receptacle;
- Allow device to dry for minimum of five minutes or per manufacturer recommendation;
- Wash hands or use alcohol gel as appropriate.
10. Observation on 12/7/2021 at 12:12 P.M., showed:
- Certified Medication Technician (CMT) I performed blood sugar monitoring (typically performed by piercing the skin to draw blood, then applying the blood to a chemically active disposable test-strip inserted into a glucometer; tracks blood glucose levels) for Resident #46;
- CMT I did not clean the glucometer and placed it back on the medication cart.
11. Observation on 12/7/2021 at 12:15 A.M., showed:
- CMT I performed blood sugar monitoring with the same multiple use glucometer for Resident #26;
- CMT I did not clean the glucometer and placed it back on the medication cart.
12. During an interview on 12/7/2021 at 12:30 P.M., CMT I said he/she should have cleaned and disinfected the glucometer between using it on each resident.
During an interview on 12/7/2021 at 2:00 P.M., the DON said he/she would expect glucometers to be cleaned and disinfected before and after use per the facility policy.
13. Record review of the facility's undated policy/procedure titled, Hoyer (a mechanical lift machine used to move or transfer a person) Disinfection, showed:
- Policy: To ensure the safety of the residents, our goal is to prevent the spread of infection;
- Procedure:
- Spray or wipe all surface with proper disinfectant;
- Allow to dry;
- Disinfect between each use.
14. Observation on 12/8/21 at 2:33 P.M., showed CNA C and CNA J obtained a mechanical lift from the hallway, did not disinfect the mechanical lift machine and entered Resident #36's room. CNA C and CNA J used the lift to transfer the resident and did not disinfect the mechanical lift machine after use. CNA C removed the mechanical lift machine from the resident's room and placed the mechanical lift in the shower room across from room [ROOM NUMBER]. Neither, CNA C or CNA J returned to the shower room to disinfect the mechanical lift machine.
During an interview on 12/8/21 at 4:00 P.M., the Director of Operations said she expected nursing staff to disinfect the community shared mechanical lift machine before and after use due to infection control. She expected nursing staff to follow the facility's policy regarding disinfecting the mechanical lift machine.
15. The facility did not provide a policy related to Tuberculosis screening (TB: a contagious lung disease spread by coughing or sneezing).
16. Record review of Resident 129's medical record, showed:
- An admission face sheet, admission date of 12/7/15 and readmission date of 11/28/20;
- Immunization record, last annual TB screen completed dated 4/19/17;
- No annual TB screen completed for 2021.
17. Record review of Resident #11's medical record, showed:
- An admission face sheet, admission date of 12/13/19 and re-admission date of 5/13/21;
- Immunization record did not contain documentation of the annual TB screen completed for 2021;
- The facility could not provide documentation of any TB screening for this resident.
18. Record review of Resident #29's medical record, showed:
- An admission face sheet, admission date of 9/26/20 and re-admission date of 11/16/21;
- Immunization record did not contain documentation of the annual TB screen completed for 2021;
- The facility could not provide documentation of any TB screening for this resident.
19. Record review of Resident #33's medical record, showed:
- An admission face sheet with an admission date of 4/22/19 and re-admission date of 11/21/21;
- Immunization record did not contain documentation of the annual TB screen completed for 2021;
- The facility could not provide documentation of any TB screening for this resident.
20. Record review of the Resident #49's medical record, showed:
- An admission date of 10/4/17 and re-admission date of 11/29/21;
- Immunization record did not contain documentation of the annual TB screen completed for 2021;
- The facility could not provide documentation of any TB screening for this resident.
21. Record review of Resident #57's medical record showed:
- An admission face sheet, admission date of 2/14/21 and re-admission date of 7/7/21;
- Immunization record did not contain documentation of the annual TB screen completed for 2021;
- The facility could not provide documentation of any TB screening for this resident.
22. Record review of Resident #76's medical record showed:
- An admission face sheet, admission date of 4/8/19 and re-admission date of 4/22/20;
- Immunization record did not contain documentation of the annual TB screen completed for 2021;
- The facility could not provide documentation of any TB screening for this resident.
23. During an interview on 12/9/21 at 11:57 A.M., the Administrator, DON, Infection Preventionist (IP), and Director of Operations said the facility could not provide documented annual TB screens for the residents and verified the annual TB screens were not completed as required.
24. Record review of the facility's policy titled, Infection Control Policy undated showed standard/universal precautions: to prevent contact with blood or other potentially infectious materials, standard/universal precautions will be utilized by facility personnel.
25. Record review of the facility's policy titled, Discontinuing of Isolation dated 1/15/19 showed:
- Purpose: This policy is to ensure that a resident is free of communicable disease and meets the criteria to come off isolation to ensure the safety of all residents and staff;
- Procedure: Assess resident's condition. Monitor for symptoms of the condition that requires isolation. Communicate residents condition and symptoms with physician. Follow physicians orders. Follow CDC guidelines if applicable. Ensure no other residents or staff are at risk.
26. Record review of Resident #49's medical record, showed:
- An admission date of 10/4/17 and re-admission date of 11/29/21;
- Diagnoses of extended spectrum beta-lactamase (ESBL: an enzyme found in some strains of bacteria harder to treat with antibiotics) urinary tract infection (UTI: an infection in any part of the urinary system), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), dementia with behavioral disturbance (a brain disease which may cause a decrease in thinking ability), and cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area);
- No documentation of resident to be on isolation.
Observation on 12/1/21 at 9:13 A.M., of the resident and his/her room showed:
- Signage on the resident's open door indicated the resident to be in isolation;
- Signage on the resident's door indicated to check with the nurse before entering;
- Plastic drawer bin sat outside of the resident's room in the hall with personal protective equipment (PPE) in it;
- The resident wore a mask, sat in the memory care unit (MCU) dining room and watched TV with staff and other residents.
During an interview on 12/2/21 at 9:06 A.M., Licensed Practical Nurse (LPN) H and LPN M said they were unsure if Resident #49 was to be on isolation or not. The resident did return from the hospital on [DATE] with an ESBL UTI, but it was treated in the hospital. They do not know if the resident needed to be on isolation. They were unsure if he/she would be because of the already treated ESBL UTI. The resident had been to the hospital and was fully vaccinated for COVID-19.
During an interview on 12/2/21 at 9:24 A.M., the Director of Nursing (DON) and the Director of Operations were unsure sure if Resident #49 was on isolation. Each said they were unsure why the resident needed to be on isolation and for how long.
27. Observation on 12/7/21 at 9:13 A.M., of Resident #13's room showed:
- Signage on the closed door which indicated the resident on some type of isolation;
- A plastic drawer bin outside of the resident's room in the hall containing personal protective equipment (PPE).
During an interview on 12/7/21 at 9:41 A.M., the Infection Preventionist (IP) said one of their Social Service Designee (SSD) was tested on [DATE] for COVID-19 during the facility's routine testing. The SSD received a positive result for COVID-19 on 12/4/21. The facility began outbreak testing of the residents for COVID-19 on 12/5/21. Resident #13 received a positive COVID-19 result on 12/6/21. He/she was placed on isolation at that time.
Observations on 12/7/21 at 8:05 A.M., 9:05 A.M., and 10:30 A.M. showed no signage posted at the facility entrance or throughout to indicate COVID-19 present in the building.
28. During an interview on 12/9/21 at 11:57 A.M., the Administrator, DON, IP, and Director of Operations said:
- They would expect infection control standards to be adhered to including washing hands, changing gloves between dirty and clean, cleaning equipment, and oxygen tubing;
- Hands washed and gloves should be changed between each location;
- Staff should change gloves before applying barrier cream or medication;
- Nasal cannulas should not be on the floor;
- Residents should not have to cut tubing to connect them to get the length they need. Long tubes are located in central supply. Nursing staff can get to the central supply area.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide information and education to each resident or the resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide information and education to each resident or the resident's representative of the pneumococcal vaccines for seven residents (Resident #7, #11, #12, #49, #57, #76, and #129) and failed to provide information and education to one resident (Resident # 57) for the influenza vaccine, out of seven sampled residents. The facility's census was 81.
Record review of the facility's policy titled, Influenza, Pneumococcal, and Covid-19 Vaccine policy, updated 12/20, showed:
- In order to minimize the risk of resident acquiring, transmitting or experiencing complications from influenza, pneumococcal pneumonia and Covid-19. It's the policy of this facility to offer influenza and pneumococcal vaccinations to all residents current or newly admitted and to assist all current or new residents with receiving the Covid-19 vaccine;
- Each resident or resident's representative will receive education regarding the benefits and potential side effects of the influenza immunization;
- Each current resident will be offered the influenza vaccination, unless the immunization is medically contraindicated or the resident refused the vaccine or received it at another location;
- Residents admitted after October 1 through March 31, shall, as medically appropriate, receive an influenza vaccination upon admission or as soon as possible unless the immunization is contraindicated or the resident refused the vaccination or the resident's vaccine status was current prior to admission;
- The resident's medical record will indicate either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal;
- Before offering or assisting with pneumococcal and Covid-19 immunizations, each resident or the resident's representative will receive education regarding the benefits and potential side effects of pneumococcal and Covid-19 immunizations;
- Each resident shall be offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized. The local County Health Department will come to the facility to administer the Covid-19 vaccine.
- The resident or legal representative has the right to refuse immunization;
- The resident's medical record will include documentation that indicates the resident received the pneumococcal or Covid-19 immunizations, did not receive the immunization due to medical contraindications or refused it.
Record review of the CDC Pneumococcal Vaccine Timing for Adults, dated 6/25/20, showed:
- CDC recommends two pneumococcal vaccines for adults: 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23);
- CDC recommends one dose of the PCV13 vaccination for all adults 65 years or older and adults 19 through [AGE] years old with certain medical conditions who have not previously received PCV13;
- CDC recommends one dose of PPSV23 vaccination for all adults 65 years or older, regardless of previous history of vaccination with pneumococcal vaccines, and adults 19 through [AGE] years old with certain medical conditions with an indication of a second dose depending on the medical condition;
- Once a dose of PPSV23 given at age [AGE] years or older, no additional doses of PPSV23 should be administered.
1. Record review of Resident #7's medical record showed:
- admitted to the facility on [DATE] and readmitted on [DATE];
- The resident [AGE] years old;
- Diagnoses include generalized anxiety disorder (a feeling of worry, nervousness, or unease), Crohn's disease (chronic inflammatory bowel disease that affects the lining of the digestive tract), colostomy (a surgical opening into the intestines for bowel elimination), insomnia (difficulty sleeping), major depressive disorder (long-term loss of pleasure or interest in life), bipolar disorder (a mental disorder with periods of elevated moods and depression) and paranoid schizophrenia (a long-term mental disorder that affects a person's ability to think, feel or behave clearly).
- No documentation of the resident's PCV13 history;
- No documentation of education provided to the resident or the representative for PCV13;
- No documentation of a consent/refusal form signed by the resident or the representative for PCV13.
2. Record review of Resident #12's medical record showed:
- admission date of 2/23/21;
- The resident [AGE] years old;
- Diagnoses include kidney failure (kidneys do not function properly), chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should);
- May have influenza, pneumonia and covid vaccines order;
- No documentation of the residents's PCV13 history;
- No documentation of education provided to the resident or the representative for PCV13;
- No documentation of a consent/refusal form signed by the resident or the representative for PCV13.
3. Record review of Resident #49's medical record showed:
- admitted to the facility on [DATE];
- The resident [AGE] years old;
- Diagnoses of hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), dementia with behavioral disturbance (a brain disease which may cause a decrease in thinking ability), and cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area);
- May have pneumonia vaccines order;
- Received Pneumovax 23 on 11/14/2017;
- No documentation of the resident's PCV13 history;
- No documentation of education provided to the resident or the resident's representative for PCV13;
- No documentation of a consent/refusal form signed by the resident or the resident's representative for PCV13.
4. Record review of Resident #57's medical record showed:
- admission date of 2/14/19;
- Resident [AGE] years old;
- Diagnoses include multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and pain;
- May have influenza, pneumonia and covid vaccines order;
- Immunization record showed resident refused influenza vaccine;
- The facility failed to provide and/or document a consent/refusal form signed by the resident or the resident's representative for the influenza vaccine;
- No documentation of the resident's PCV13 history;
- No documentation of education provided to the resident or the resident's representative for PCV13;
- No documentation of a consent/refusal form signed by the resident or the resident's representative for PCV13.
5. Record review of Resident #11's medical record showed:
- admission date of 12/13/19 and readmission date of 5/13/21;
- The resident [AGE] years old;
- Diagnoses included bipolar disorder (a mental disorder that causes unusual shifts in mood) and chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that causes obstructed airflow from the lungs);
- No documentation of the resident's PCV13 history;
- No documentation of education provided to the resident or the representative for PCV13;
- No documentation of a consent/refusal form signed by the resident or the representative for PCV13.
6. Record review of Resident #76's medical record showed:
- admission date of 4/8/19;
- Resident [AGE] years old;
- May have influenza, pneumonia and covid vaccines order;
- Diagnoses include venous insufficiency (difficulty with blood returning to the heart from the legs), depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic pain (pain that is ongoing and usually lasts longer than six months);
- No documentation of the resident's PCV13 history;
- No documentation of education provided to the resident or the resident's representative for PCV13;
- No documentation of a consent/refusal form signed by the resident or the resident's representative for PCV13;
- No documentation of the resident's PPSV23 history;
- No documentation of education provided to the resident or the resident's representative for PPSV23;
- No documentation of a consent/refusal form signed by the resident or the resident's representative for PPSV23.
7. Record review of Resident #129's medical record showed:
- admission date of 12/7/15 and readmission date of 11/28/20;
- The resident [AGE] years old;
- Diagnoses included COPD, major depressive disorder and dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning);
- Immunization record, documented refused (no documented date of refusal) and/or date offered for the PCV13;
- No documentation of education provided to the resident or the representative for PVC13;
- No documentation of a consent/refusal form signed by the resident or the representative for PCV13.
During an interview on 12/7/21 at 3:49 P.M., the MDS Coordinator said that pneumonia vaccines are offered upon admission but not reviewed annually. They do not document that they offer the vaccine.
During an interview on 12/9/21 at 11:55 A.M., the Director of Operations verified the pneumococcal vaccine was not offered and/or administered for Residents #11, #12, #76 and #129. The dates of education and refusal by resident #57 are not documented.
During an interview on 12/9/21 at 11:57 A.M., the Administrator and the Director of Nursing said they would expect influenza, pneumococcal and annual TB assessments to be offered, documented and completed. It is the responsibility of the nursing staff to ensure immunization accuracy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to inform residents, their representatives, and families by 5:00 P.M., the next calendar day following a confirmed infection of COVID-19 (a high...
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Based on observation and interview, the facility failed to inform residents, their representatives, and families by 5:00 P.M., the next calendar day following a confirmed infection of COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus). SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2 is the coronavirus that causes COVID-19, the respiratory illness responsible for the ongoing COVID-19 pandemic) is thought to spread from person to person through droplets released when an infected person coughs, sneezes, or talks. The facility's census was 81.
During an interview on 12/7/21 at 9:41 A.M., the Infection Preventionist (professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections) said one of the facility staff received positive Covid-19 results on 12/5/21. The facility began outbreak testing on 12/5/21 and Resident #13 received positive results on 12/6/21.
Observation on 12/7/21 at 10:31 A.M., of Resident #39 showed the resident sat in the front lobby visiting with family.
During an interview on 12/7/21 at 10:32 A.M., Resident #39's family said they called on 12/6/21, and made an appointment to visit the resident on 12/7/21. The staff told the family, there had been a Covid-19 positive staff member in the facility. When the family arrived at the facility on 12/7/21, they were not told there was an additional Covid-19 positive case in the facility.
During an interview on 12/7/21 at 11:21 A.M., the Social Service Designee said the facility mails letters to families to notify them of positive cases in the building. He/she does not believe they are notified within 24 hours. The staff should be telling the residents that there are positive cases. Staff get a group text and as far as he/she knows everyone on staff is included in the text.
During interviews on 12/07/21 at 12:03 P.M., Residents #46, #329, and #26, said they had heard from other residents that there was COVID-19 in the facility but staff had not informed them. They said the staff never tell them that stuff.
During an interview on 12/07/21 at 12:10 P.M., the Administrator said they notify families and responsible parties by letter. The letter is mailed within 24 hours of a positive case being found. Staff are informed in the morning meetings and the nurse informs the rest of the staff that there is Covid-19 in the building. The nursing staff are supposed to tell the residents.
During an interview on 12/9/21 at 11:57 A.M., the Director of Operations and Administrator said residents and/or their families/responsible parties, and physicians are sent a letter within 24 hours of a new positive case of Covid-19 among residents and/or staff members. The Social Worker is supposed to make phone calls to the families and responsible parties about positive cases. The administrator does not know if the social worker is actually making the calls or if it has been done consistently. The administrator said the facility sent a letter with the recent positive case, she cannot say if the phone calls were made.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an effective pest control program. This practice affected fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an effective pest control program. This practice affected four residents (Resident #25, #33, #36, and #55) out of the 20 sampled residents and three residents (Resident #17, #26, and #46) outside the sample and had the potential to affect all residents in the facility. The facility's census was 81.
Observations of the facility showed:
- On 11/30/21 at 9:45 A.M., a sticky fly trap with multiple bugs hung next to the window in Resident #33's room;
- On 11/29/21 at 2:20 P.M., two dead crickets on the floor just inside double doors from 100 hall to D wing dining room;
- On 11/30/21 at 8:30 A.M., twelve dead bugs including crickets on the floor from the double doors at 100 hall to D wing hallway;
- On 11/29/21 at 11:47 A.M., a sticky mouse trap was on the floor under the window in Resident #25's room. The sticky mouse trap contained multiple dead bugs.
During an interview on 11/29/21 at 11:47 A.M., Resident #25 said he/she has caught three mice on sticky traps since he/she has been at the facility. The resident said that he/she asks maintenance for new sticky mouse traps when needed.
During an interview on 11/30/21 at 9:45 A.M., Resident #33 said the flies were bad.
During an interview on 11/29/21 at 12:42 P.M., Resident #17 said his/her room is never cleaned, there are crickets in the building, the floor is always dirty, the showers are not cleaned, he/she found mouse droppings in his/her oatmeal.
During an interview on 11/29/21 at 1:30 P.M., Resident #46 said they do not clean the room. He/she sees a lot of flies and will use his/her own fly swatter.
During an interview on 11/29/21 at 1:30 P.M., Resident #26 said there are a lot of flies and he/she has his/her own fly swatter.
During an interview on 11/30/21 at 9:40 A.M., Resident #36 said he/she saw a mouse run across the floor under the cabinet next to the sink, probably a couple months ago.
Observation on 11/29/21 at 1:03 P.M. and 12/7/21 at 9:18 A.M., showed room [ROOM NUMBER] with two unidentifiable dead bugs partially under the nightstand.
During an interview on 11/29/21 at 1:03 P.M., Resident #55 said there were two dead bugs he/she killed several days ago. He/she placed the nightstand over them because housekeeping never comes in to clean his/her room and he/she was tired of looking at them.
During an interview on 12/9/21 at 11:57 A.M., the Administrator and Director of Operations said they would not expect there to be dead insects on the floor for several days without being cleaned.
The facility did not provide a pest control policy or invoices for a pest control program.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment. This d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect every resident at the facility. The facility's census was 81.
1. Observations on 11/29/21 at 11:58 A.M. through 1:46 P.M., of rooms 300, 301, 302, 303, 304, 305, 306, 307, 308, and 309 located on the A-wing of the facility showed:
- The paint on the doors and door frames were chipped with peeled paint;
- The drawers and doors to the wooden built-in wall units did not close;
- A build up of black grime and dirt along all baseboards and in corners of rooms;
- The room walls and doors were scuffed with black marks.
2. Observation on 11/29/21 at 1:00 P.M., of room [ROOM NUMBER] showed:
- A dried, brown liquid stain ran down the wall at the head of the bed. Two ceiling tiles, directly above the bed, had a large, dark brown stain;
- Numerous small dark gray spots on the wall just below the ceiling over the head of the bed;
- A cob web, drifted down approximately eight inches long from the ceiling at the side of the bed;
- The sink with the enamel chipped away and rusted metal showing;
- The countertop around the sink peeled;
- A trash can overflowed with trash on the floor, a trash bag lay on the floor open and full, and spilled it's contents onto the floor;
- The bathroom trash can overflowed with two used disposable undergarments on top of the can. A second trash can overflowed with paper towels and other trash;
- The bathroom floor around the toilet contained a yellow stain around the base of the toilet;
- The toilet bowel contained dried feces from the water up to the rim of the bowl;
- The bathroom smelled of urine.
During an interview on 12/3/21 at 1:02 P.M., the resident in room [ROOM NUMBER] said the trash bag has been sitting on the floor for two days.
3. Observation on 11/29/21 at 1:05 P.M., of room [ROOM NUMBER] showed:
- A strong urine odor;
- A sticky, orange dried liquid on the floor;
- The bedside tables had rusted legs and dried food and liquid on them;
- An oxygen mask lay on the floor under a nightstand;
- A soiled surgical mask lay on the floor;
- A bag of trash on the floor;
- A foam bed wedge on the floor;
- Food crumbs and plastic wrappers covered the floor under the beds;
- The sink stained with red drops;
- Three soiled wash cloths lay in the sink.
4. Observation on 11/29/21 at 1:10 P.M., of room [ROOM NUMBER] showed:
- The bedside tables had rusted legs and dried food and liquid on them;
- A denture cup lay on the floor;
- Daylight could be seen through a gap between the wall and the heat/air conditioner;
- The bed sheets stained with brown substance.
5. Observation on 11/29/21 at 1:20 P.M., of room [ROOM NUMBER] showed:
- The bedside tables had rusted legs and dried food and liquid on them;
- Table tops with dried stains and dried, sticky pools of liquids.
6. Observation on 11/29/21 at 1:30 P.M., of room [ROOM NUMBER] showed:
- The bedside tables had rusted legs and dried food and liquid on them;
- Table tops with dried stains and pools of liquid;
- Soiled paper towels on the floor;
- The countertop around the sink peeled;
- The sink with gray stains;
- The floor under the toilet stain yellow;
- The floor in front of the toilet discolored with a gray stain;
- Two bedpans full of feces stacked on top of each other next to the toilet.
7. Observation on 11/29/21 at 1:38 P.M., of room [ROOM NUMBER] showed:
- Paper trash on the floor;
- A red stain under the bed;
- Bathroom trash can without a liner and a dried, dark brown crusty substance smeared on the inside.
8. Observation on 11/29/21 at 1:42 P.M., of room [ROOM NUMBER] showed:
- The sink with the enamel chipped away and rusted metal showing;;
- The countertop around the sink peeled;
9. Observation on 11/29/21 at 1:03 P.M. and 12/7/21 at 9:18 A.M., of room [ROOM NUMBER] showed:
- Multiple pieces of food and dirt streaks on the floor;
- Two unidentifiable dead bugs partially under the nightstand;
- A hole in the drywall, approximately two inches in diameter, on the right side at the foot of the resident's bed.
During an interview on 11/29/21 at 1:03 P.M., the resident in room [ROOM NUMBER] said there were two dead bugs he/she killed several days ago. He/she placed his/her nightstand over them because housekeeping never comes in to clean his/her room and he/she was tired of looking at them.
10. Observations on 11/29/21 at 10:30 A.M., on 11/30/21 at 11:00 A.M., on 12/1/21 at 12:30 P.M., on 12/2/21 at 11:30 A.M. and on 12/7/21 at 10:40 A.M., of room [ROOM NUMBER] on B Hall, showed the following:
- Floors in room and bathroom dirty with dried sticky substance;
- Multiple black scuff marks, measured approximately 4 to 8 inches on the room and bathroom doors;
- Heavy build up of dirt around the faucets on the sink;
- The cold water faucet handle with a portion of the handle broken off;
- Multiple broken slats on both window blinds.
11. Observations on 11/19/21 at 10:00 A.M., on 11/30/21 at 11:00 A.M., on 12/1/21 at 2:00 P.M., on 12/2/21 at 10:00 A.M., and on 12/7/21 at 10:30 A.M., of room [ROOM NUMBER] on B Hall, showed the following:
- Floor in room, dirty with multiple dried black stains;
- Multiple black and blue scuff marks, measured approximately 4 to 10 inches on the walls next to the door and above the head of the bed;
- Multiple areas of peeled paint, measured approximately 4 to 6 inches on the bathroom door;
- The cabinets/drawers next the sink in the room with chipped paint and portions of the wood gone;
- Thick, heavy build up of dirt and grime on the bathroom floor;
- Approximately 12 inches of cove baseboard pulled away from the wall next to the toilet;
- Multiple black scuff marks that measured approximately 2 to 4 inches on each wall in the bathroom.
12. Observations on 11/29/21 at 11:00 A.M., on 11/30/21 at 10:00 A.M., on 12/1/21 at 12:30 P.M., on 12/2/21 at 10:00 A.M. and on 12/7/21 at 11:00 A.M., of room [ROOM NUMBER] on B Hall, showed the following:
- Heavy build up of dirt, grime and a sticky substance on the floor in the room and bathroom;
- Multiple black scuff marks that measured approximately 4 to 6 inches on the room and bathroom doors;
- Multiple areas of peeled paint measured approximately 4 to 8 inches on the walls in the room and bathroom;
- Dried and sticky substance on top of the bedside table;
- Heavy build up of rust on the legs of the bedside table.
13. Observations on 11/29/21 at 11:00 A.M., on 11/30/21 at 10:00 A.M., on 12/1/21 at 11:00 A.M., on 12/2/21 at 10:30 A.M., and on 12/7/21 at 11:30 A.M., of room [ROOM NUMBER] on B Hall, showed the following:
- Multiple dried black stains on the floor in the room;
- Bathroom floor dirty and sticky;
- Bedside table dirty with sticky dried substance on top of the bedside table and legs of the bedside table;
- Heavy build up of rust on the legs of the bedside table.
14. Observation on 12/1/21 at 9:30 A.M., of the 300 hall shower room showed:
- The shower wall with peeled paint;
- A mechanical lift sat in the shower area. The lift legs contained a heavy build up of rust;
- A piece of a vinyl glove lay on the base of the lift;
- The shower drain contained a build up of rust;
- The tub area to have a shower curtain rod fallen and laying in the tub with a vinyl curtain on it;
- Three hoyer lifts sitting in the room, two with rusted legs;
- The toilet area to have plastic wrappers, used tissue and paper towels on the floor;
- The trash can overflowed;
- The water pipes with peeled paint and a build up rust;
- The lid to the toilet tank did not fit properly and sat crooked on top of the tank;
- The walls contained black scuff marks;
- The white tiled floors contained two red dried areas. One area about 1.5 inches by 1 inch and the other area about 1 inch by 1 inch;
- The floor contained an area of gray stain in the center and black build up along the baseboards;
- The entry/exit door contained areas of chipped paint and black scuff marks;
- The metal door frame contained areas of chipped paint along the edges.
15. Observations throughout the facility 11/29/21 through 12/2/21 showed:
- The facility hallways with a strong smell of urine;
- Dead crickets in the hallway off of the B-wing;
- Hallways contained disposable food trays which sat outside of doorways after meals;
- [NAME] tiled floors in the hallways are scuffed with black marks, black grime build up present along baseboards and in corners;
- Metal doors were chipped with peeling paint.
16. Observation on 12/2/21 at 9:40 A.M. and on 10:49 A.M., of room [ROOM NUMBER] showed:
- A brown liquid stain on the wall by the window which ran from the ceiling to the floor;
- Two brownish red spots on the wall, each area about 1 inch;
- A brownish red handprint over the head of the bed.
17. Observation on 12/2/21 at 10:33 A.M., of the shower room on the 100 hall memory unit showed:
- Circular, gray, slimy looking build up covered wall behind the tub, the wall around the window all the way to the sink;
- [NAME] stains covered the ceiling around the vent behind the tub.
18. Observations on 12/8/21 at 11:00 A.M., of room [ROOM NUMBER] showed:
- Two bedpans full of feces stacked on top of each other, next to the toilet;
- The trash can overflowing with disposable undergarments.
Observations on 12/8/21 at 11:05 A.M., of room [ROOM NUMBER] showed:
- The toilet had dried feces from the water up to the rim of the bowl.
19. Observation on 11/30/21 at 12:40 P.M. of room [ROOM NUMBER] showed the metal legs of both of the bedside tables soiled with grime. Resident #4's wheelchair with a brown substance smeared on the right side metal under the arm rest, and the sink with rusted metal showing. The room smelled of body odor and feces.
20. Observation on 11/30/21 at 9:50 A.M. of room [ROOM NUMBER] showed four discolored ceiling tiles.
21. Observations of room [ROOM NUMBER] showed:
- On 11/29/21 at 12:50 P.M., brown and black stains on the dividing curtain and walls, a brown substance smeared on the wall above the head of Resident #180's bed. Peeling paint on the ceiling above the sink. Food on Resident #180's chair and on the floor around it;
- On 11/30/21 at 9:40 A.M., red liquid spilled on the floor next to the head of Resident #180's bed, a piece of pasta on the floor next to the chair, and scrambled egg on the floor in front of the chair. [NAME] and black splotches on both sides of the dividing curtain. Trash on the floor including a plastic cup lid;
- On 12/1/21 at 9:15 A.M. a red stain on the floor next to the head of Resident #180's bed, trash on floor, stains on both sides of the dividing curtain, and grime around the baseboards.
- On 12/7/21 at 12:20 P.M. a red stain on the floor next to the head of Resident #180's bed, trash on the floor, stains on both sides of the dividing curtain, and grime around the baseboards.
- On 12/8/21 at 10:38 A.M. a red stain on the floor next to the head of Resident #180's bed, trash on the floor. The cabinets and closet had peeling paint, lime buildup around the sink's faucets, and grime around the baseboards.
22. Observation of room [ROOM NUMBER] showed:
- On 12/1/21 at 9:16 A.M., lines of a brown substance running down the wall from the ceiling to the top of the window;
- On 12/8/21 at 10:45 A.M., peeling paint on the bathroom door, sink, and cabinets.
23. Observation on 11/30/21 at 9:45 A.M. room [ROOM NUMBER] showed the dividing curtain with brown stains running down. The sink with rusted metal showing on the end opposite of the faucet.
24. Observations of the facility showed:
- On 11/29/21 at 2:20 P.M., a tissue, leaves, cobwebs, dust and debris in the floor in the D wing dining room and hallways;
- On 11/30/21 at 8:30 A.M. cobwebs, leaves, dirt, and debris in the D wing dining room;
- On 12/1/21 at 12:09 P.M., a pile of dust and debris in the floor next to the Christmas tree in the main dining room.
25. During a tour of the A-wing, on 12/8/21 at 1:44 P.M., the head of housekeeping and the Administrator observed and acknowledged lack of cleaning in rooms and bathrooms for rooms 301, 307, 312, 313 and 314. They said that the bathrooms need to be cleaned, bedpans should not be left in the bathrooms, the drips from the ceiling are from a leaking roof that has been fixed, and they are waiting on ceiling tiles to come in to replace the stained ones. They said there are plans to remodel all the rooms so the chipped and peeling paint will be taken care of and the floors will be stripped and waxed so the black grime will come up. They said the sinks need to be replaced and acknowledged the handprint on the wall in room [ROOM NUMBER]. They agreed that bedside tables need to be cleaned and/or replaced along with the wheelchairs that are damaged.
26. Record review of the Resident Council minutes showed:
- On 9/8/21, the residents in attendance said rooms are not getting swept and mopped regularly, residents would like the liners to be taken out of their trash cans and the trash to be taken from their rooms;
- On 10/6/21, the residents said the rooms are not getting swept and mopped regularly and rooms are not being stocked with toiletries;
- On 11/10/21, the residents said rooms are not getting swept and mopped regularly and rooms are not being stocked with toiletries;
- The facility did not provide a response to the resident concerns.
27. During an interview on 12/8/21 at 10:05 A.M., Housekeeper K said all resident rooms and bathrooms are cleaned daily which included mopping resident room and bathroom floors, cleaning the sinks, bedside tables, dusting furniture, cleaning toilets and emptying trash cans in each of the resident's rooms and bathrooms. The housekeeper said each day, one resident's room/bathroom was deep cleaned with removal of their beds and furniture out of the room, floors mopped/waxed in the resident's room/bathroom, and removal of their privacy curtain. The resident's privacy curtain is taken to the laundry room and washed. The housekeeper said if any equipment in the resident's room or bathroom is broken, staff are expected to complete a work order and place it in the maintenance box on the wall in the employee hall of the facility. He/she said every hall has a daily housekeeping schedule to follow for the hall they are assigned to clean.
28. During an interview on 12/8/21 at 10:09 A.M., Licensed Practical Nurse (LPN) L said the facility has a work order form for maintenance staff and it is maintained in the employee hall of the facility. He/she said if it is a minor repair in the resident's room and/or bathroom, sometimes he/she would not fill out a work order for the problem and instead call maintenance staff directly regarding the problem.
29. During an interview on 12/8/21 at 10:17 A.M., the Housekeeping/Laundry Supervisor and maintenance assistant said housekeeping staff are expected to clean every resident's room/bathroom daily on A, B and C Wings on each hall. The housekeeping staff have a daily assignment schedule of what is expected to be cleaned/disinfected for each wing. The housekeeping staff should clean each resident's room/bathroom, including damp mopping floors, dusting furniture, cleaning all sinks, toilets and bedside tables. He said one resident's room is deep cleaned daily which included removal of all furniture, beds, and bedside tables, and floors are damped mopped/waxed and privacy curtains are removed and taken to laundry to be washed/dried. He said when the privacy curtains are washed, they are put back up in the resident's room. The housekeeping/laundry supervisor said he expected all housekeeping staff to follow their assignments regarding what is required to be cleaned in each resident's room/bathroom. He said the facility has three full time housekeeping staff now, but did not have enough housekeeping staff to maintain and clean resident rooms/bathrooms in the previous months. He said all managers of the facility do walking rounds at least every two to three hours daily which included checking on resident rooms/bathrooms, common use areas, dining room area, kitchen area, hallways and lobby area. The housekeeping/laundry supervisor said generally all repairs are completed within 24 hours, unless the repair requires supplies and/or parts to be ordered.
30. Record review of the Housekeeping staff B-Hall daily cleaning duties/schedule, showed:
-7:20 A.M. to 9:00 A.M.:
-Disinfect and make all stripped beds;
-Clean and stock staff/employee bathroom;
-Disinfect handrails and sanitizer dispensers on both sides of the hallway;
-Clean B-Hall dining room, disinfect window sills, blinds, baseboards, tables, light switches/door knobs, check wall for cleanliness, sweep/mop floors and vacuum carpet;
-9:15 A.M. to 11:15 A.M.:
-Start with room [ROOM NUMBER] and work your way to the top of the hall, disinfect door knobs (inside and outside), disinfect light switches, sink, counter, soap dispenser, paper towel dispenser, clean mirrors with glass cleaner, dust television, blinds, corner of ceiling, walls, window sills, under sink, stock paper towels, soap/toilet paper, clean windows/window sills, disinfect night stands (top to bottom), disinfect bed side tables (top to bottom), disinfect refrigerators (inside and outside), check refrigerators for expired food, disinfect chairs, check walls for cleanliness, take out the trash, disinfect trash cans (inside and outside), disinfect bathroom door knobs, light switches, hand rails, pull strings, toilets, scrub toilets (inside and outside), spray air freshener on baseboards, curtains, bed spreads, sweep/mop entire room and under furniture;
-11:45 A.M. to 12:00 P.M.:
-Continue to clean resident rooms including, clean utility, soiled utility, staff/visitor bathroom, shower room [ROOM NUMBER] and shower room [ROOM NUMBER];
-12:00 P.M. to 12:20 P.M.:
-Clean B Hall dining room, disinfect window sills, blinds, baseboards, tables, light switches, door knobs, check walls for cleanliness, sweep/mop floors and vacuum carpet;
-12:20 P.M. to 1:15 P.M.:
-Continue to clean resident rooms, nurse's station, social service office, resident lounge to include dusting corners, walls, shelves, take out trash, disinfect door knobs, desk, trash cans, tables, carts, chairs and sweep/mop floors;
-1:30 P.M. to 2:45 P.M., continue to clean resident rooms.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
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, facility staff failed to complete a quarterly Minimum Data Set (MDS: a federally mandated ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to complete a quarterly Minimum Data Set (MDS: a federally mandated assessment instrument completed by the facility staff), within the required timeframes for 16 residents (Residents #7, #8, #11, #25, #29, #31, #33, #36, #42, #49, #52, #55, #71, #76, #78, and #129) out of 20 sampled residents and 27 residents (Resident #3, #6, #9, #13, #15, #16, #19, #21, #23, #26, #27, #28, #32, #34, #35, #37, #39, #40, #43, #44, #45, #47, #48, #51, #57, #65, and #66) outside the sample. The facility's census was 81.
1. Record review of Resident #3's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- No quarterly MDS dated for 6/2021 completed;
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
2. Record review of Resident #6's MDS records showed:
- admission to the facility on 9/4/19;
- Quarterly MDS dated [DATE];
- An incomplete annual MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
3. Record review of Resident #7's MDS records showed:
- admission to the facility on 8/25/20;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS.
4. Record review of Resident #8's MDS records showed:
- admission to the facility on 5/13/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
5. Record review of Resident #9's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
6. Record review of Resident #11's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
7. Record review of Resident #13's MDS records showed:
- admission to the facility on 5/25/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
8. Record review of Resident #15's MDS records showed:
- admission to the facility on 6/14/17;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
9. Record review of Resident #16's MDS records showed:
- admission to the facility on 3/18/19;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
10. Record review of Resident #19's MDS records showed:
- admission to the facility on 5/11/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
11. Record review of Resident #21's MDS records showed:
- admission to the facility on 3/25/19;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
12. Record review of Resident #23's MDS records showed:
- admission to the facility on 3/17/21;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
13. Record review of Resident #25's MDS records showed:
- admission to the facility on 6/23/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
14. Record review of Resident #26's MDS records showed:
- admission to the facility on [DATE];
- Annual MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
15. Record review of Resident #27's MDS records showed:
- admission to the facility on 6/9/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
16. Record review of Resident #28's MDS records showed:
- admission to the facility on 6/10/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
17. Record review of Resident #29's MDS records showed:
- admission to the facility on 9/6/20;
- Quarterly MDS dated [DATE];
- No quarterly MDS dated for 3/2021 completed;
- Quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
18. Record review of Resident #31's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
19. Record review of Resident #32's MDS records showed:
- admission to the facility on 7/2/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
20. Record review of Resident #33's MDS records showed:
- admission to the facility on 4/22/19;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
21. Record review of Resident #34's MDS records showed:
- admission to the facility on 4/27/18;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
22. Record review of Resident #35's MDS records showed:
- admission to the facility on 6/14/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
23. Record review of Resident #36's MDS records showed:
- admission to the facility on 3/24/21;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
24. Record review of Resident #37's MDS records showed:
- admission to the facility on 3/23/21;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
25. Record review of Resident #39's MDS records showed:
- admission to the facility on 3/15/19;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
26. Record review of Resident #40's MDS records showed:
- admission to the facility on 5/26/16;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
27. Record review of Resident #42's MDS records showed:
- admission to the facility on 6/7/21;
- admission MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
28. Record review of Resident #43's MDS records showed:
- admission to the facility on 3/15/21;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
29. Record review of Resident #44's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
30. Record review of Resident #45's MDS records showed:
- admission to the facility on 3/20/20;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
31. Record review of Resident #47's MDS records showed:
- admission to the facility on 2/17/17;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
32. Record review of Resident #48's MDS records showed:
- admission to the facility on 7/1/19;
- Annual MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
33. Record review of Resident #49's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
34. Record review of Resident #51's MDS records showed:
- admission to the facility on 3/24/21;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
35. Record review of Resident #52's MDS records showed:
- admission to the facility on 1/31/19;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
36. Record review of Resident #55's MDS records showed:
- admission to the facility on 8/7/19;
- Annual MDS dated [DATE];
- No quarterly MDS dated for 10/2021 completed;
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
37. Record review of Resident #57's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
38. Record review of Resident #65's MDS records showed:
- admission to the facility on 8/19/15;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
39. Record review of Resident #66's MDS records showed:
- admission to the facility on 3/24/21;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
40. Record review of Resident #71's MDS records showed:
- admission to the facility on 1/12/21;
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
41. Record review of Resident #76's MDS records showed:
- admission to the facility on 4/8/19;
- Annual MDS dated [DATE];
- No quarterly MDS dated for 10/2021 completed;
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
42. Record review of Resident #78's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
43. Record review of Resident #129's MDS records showed:
- admission to the facility on [DATE];
- Quarterly MDS dated [DATE];
- An incomplete quarterly MDS dated [DATE];
- The facility did not complete quarterly MDSs for the resident within 92 days of the last MDS.
44. During an interview on 12/7/21 at 3:27 P.M., the Infection Preventionist and the Director of Operations said the previous MDS Coordinator gave his/her resignation and the facility has another nurse working on MDSs two days a week. The facility is currently in transition and does not have a MDS Coordinator and the MDSs haven't been completed and/or transmitted in the appropriate timeframe.
During an interview on 12/9/21 at 11:57 A.M., the Director of Nursing and the Administrator said the facility would expect MDS assessments to be completed accurately, timely, and submitted on time.
The facility did not provide a policy on completing quarterly MDS assessments.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
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 failed to establish a process to identify each shift included a Cardiopulmona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a process to identify each shift included a Cardiopulmonary Resuscitation (CPR: a process of providing rescue ventilation and chest compressions to maintain circulation of blood) certified staff member and for code status to be communicated throughout the facility so that staff know immediately what action to take when an emergency arises. This practice could effect all residents. The facility's census was 81.
Record review of the facility's policy titled, CPR, dated [DATE], showed:
- Prior to the arrival of emergency medical services, the facility must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR certified staff must be available at all times;
- Staff will be scheduled accordingly to ensure that there is at least one CPR certified staff member in the building.
Record review of the facility's nursing schedule for licensed and certified personnel for the weeks of [DATE] through [DATE] showed:
- The facility provided the nursing schedule during the survey process;
- The nursing schedule identified none of the staff members scheduled for night shift of 6:00 P.M. through 6:00 A.M. for the dates of [DATE], [DATE], [DATE], and [DATE] had a valid documentation of a current CPR training;
- The nursing schedule identified none of the staff members scheduled for day shift of 6:00 A.M. through 6:00 P.M. for the dates of [DATE], [DATE], and [DATE] had a valid documentation of a current CPR training.
During an interview on [DATE] at 11:57 A.M., the Administrator, Director of Nursing, and Director of Operations said they would expect there to be a CPR certified staff member on each shift.
During a telephone interview on [DATE] at 12:33 P.M., the Administrator said the ADON (Assistant Director of Nursing) is responsible for making the schedule for the licensed nursing staff, and Restorative Aide/Scheduling (RA) O is responsible for making the schedule for the nurse aides. They should both know there is supposed to be a CPR certified staff member on every shift.
During a telephone interview on [DATE] at 12:40 P.M., RA O said she is responsible for making the schedule for the nurse aides and that there should be a CPR certified staff member on every shift.
During a telephone interview on [DATE] at 3:56 P.M., the Administrator said if any staff other than those listed on the run sheet worked, they are added to the sheet, so the sheets given would be accurate. The facility keeps a photo copy of the staff member's CPR certification card in their employee file.
During a telephone interview on [DATE] at 3:56 P.M., RA O said she has agency staff working on every shift and they all have to be CPR certified to work.
During a telephone interview on [DATE] at 5:16 P.M., the ADON said she does assist with scheduling and is aware that someone who is CPR certified must be scheduled each shift. The ADON said she is there almost everyday and she is CPR certified, she is also there some nights. Ninety percent of the staff scheduled are agency staff and the agency requires them to be CPR certified so that is how she knows there is always someone working with CPR certification.
Further record review on [DATE] of the facility's agency staff's CPR certification cards provided on [DATE] showed the shifts in question were covered by agency staff.
During a phone interview on [DATE] at 8:50 A.M., Restorative Aide (RA) O said the only way the staff know the code status of the residents that reside on the secure memory care unit (MCU) is to look at the residents' hard charts to see their code status. Unfortunately, the residents' hard charts are kept at the secure 200 Hall nurses' station and the MCU staff have to leave the secured unit and go to the 200 Hall secured unit to look up a specific resident's code status in case of an emergency such as a code situation.
At the time of the survey process, the Administrator was not aware of the process for ensuring each shift had a CPR certified staff member scheduled.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This practice affected three residents (Resident #17, #...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This practice affected three residents (Resident #17, #28, and #57) outside of the 20 sampled residents and had the potential to affect all residents. The facility's census was 81.
Record review of the facility's policy titled, Daily Kitchen Checklist, dated 2/25/16, showed all work counters are cleaned and sanitized after use, and oven spills are cleaned.
Record review of the facility's policy titled, Weekly Kitchen Checklist, dated 2/25/16, showed clean pantries, shelves and food canisters, and clean ovens weekly or as needed.
Record review of the facility's policy titled, Monthly Kitchen Checklist, dated 2/25/16, showed clean ice machine.
Record review of the facility's undated policy titled, Dietary Infection Control and Safety Checklist showed all food services are clean and food is stored in original container or a food grade container.
Record review of the facility's undated policy titled, Kitchen Sanitation Checklist, showed:
- Shelves clean and free of dust;
- Daily cleaning schedule completed and followed;
- All floors, walls, ceilings and work areas are clean;
- All work tables and drawers clean and neat;
- Employees wearing clean, appropriate hair coverings;
- Food contact surfaces cleaned and sanitized after each use;
- Toaster clean;
- Range/oven clean;
- Carts including wheels clean;
- Ice machine clean;
- No cracks, holes, or loose molding.
Observation of the kitchen on 11/29/21 at 10:53 A.M., showed:
- Mold buildup on the drain gap of the ice machine;
- A box with potatoes stored on the floor;
- A white 30 gallon trash barrel on a roller pedestal used to store oatmeal, filled to near the top, lid not sealed tightly;
- A black, crusty substance on the stove burners and bottom of the oven;
- Paint peeling on the top of the toaster and the inside tray filled with crumbs;
- [NAME] grease buildup covered the top edge of the work counter;
- Cracks in the caulking where the work counter is attached to the wall;
- Five of the six knobs missing on the stove;
- A black, brown greasy substance covered the backsplash of the stove;
- A brown greasy substance with bits of dried food particles covered the grill of the stove;
- Melted plastic on the shelf over the stove;
- A thick layer of dust covered the top of the free standing stove;
- A brown, greasy substance with food particles covered the doors of the free standing stove;
- A crusty, black substance covered the bottom of the oven;
- A food prep table next to the stove had rusted legs with peeling paint;
- A buildup of mildew on the top seal of the left door of the walk in refrigerator;
- A dried pool of brown liquid on the bottom shelf of a work table;
- Each shelf in the dry storage unit had a layer of dust, peeling paint and rusted legs;
- The rolling shelving unit had dust on each shelf, rusted legs and greasy buildup;
- The walk in freezer unit had a non-working thermometer and black buildup on the threshold;
- A two shelf wheeled cart had rust and a buildup of dirt on the wheels;
- A four shelf wheeled cart had rusted wheels;
- Dust and crumbs covered the top of the dishwasher;
- A stack of serving trays with cracked corners with metal showing;
- The handwashing sink had three chips in the enamel with rust showing through (1 1/2 inch x 1/2 inch) (1/2 inch x 1/4 inch) (1/4 inch x 1/4 inch), the white enamel with gray stains and dirt, and lime buildup around faucets.
Observation of the kitchen on 11/29/21 at 1:28 P.M. showed dietary staff placed a total of 15 resident lunch trays on an uncovered hall cart with no lids, leaving the food exposed. Dietary staff transported the food cart with the uncovered food from the employee hallway outside the kitchen with four staff and two residents present in the hallway, approximately 60 feet onto the B Wing secured locked unit. Nursing staff served the residents' meal trays at this time.
Observation of the kitchen on 11/30/21 showed:
- At 1:05 P.M., dietary staff placed resident lunch trays on an open hall cart, uncovered;
- At 1:16 P.M., dietary staff placed covers on the plates and sent the uncovered cart out for delivery to the residents;
- At 1:20 P.M,, dietary staff placed resident lunch trays on an open hall cart, uncovered;
- At 1:35 P.M., dietary staff placed covers on the plates and sent the uncovered cart out to 200 hall for delivery to the residents.
Observation on 12/7/21 at 11:50 A.M. showed one gallon of whole milk in the walk in refrigerator with an expiration date of 12/5/21, about 1/4 full, one gallon of whole milk unopened with an expiration date of 12/6/21 and one gallon of 2% milk unopened with an expiration date of 12/7/21. A carton of six dozen eggs with one cracked egg in the carton.
Observation on 12/7/21 at 12:00 P.M. showed Dietary Aide (DA) R had a two inch full beard without a beard restraint. DA R prepared food with no facial hair covering.
Observation on 12/8/21 at 8:25 AM showed one gallon of whole milk with an expiration date of 12/6/21 and one gallon of 2% milk with an expiration date of 12/7/21, both unopened.
During an interview on 11/29/21 at 12:42 P.M., Resident #17 said he/she has found mouse droppings in his/her oatmeal.
During an interview on 12/7/21 at 9:40 A.M., Resident #57 said he/she had soured milk on his/her breakfast tray this morning.
During an interview on 12/7/21 at 12:00 P.M., DA R said he/she thought the mask would be enough to cover his/her beard.
During an interview on 12/9/21 at 11:57 A.M., the Regional Dietary Manager (RDM) said soured milk should be disposed of and not served. The RDM would expect food to be stored in a food grade container with a tight seal. He/She would expect the stove and oven to be clean without food cooked or baked on the burners and bottom of the oven. He/She would expect the stove to have a control knob for each burner. All staff should have all facial hair covered while in the kitchen, male or female.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to complete the comprehensive facility assessment in accordance with all applicable Federal requirements. Failure to complete the comprehensiv...
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Based on interview and record review, the facility failed to complete the comprehensive facility assessment in accordance with all applicable Federal requirements. Failure to complete the comprehensive facility assessment could delay the services needed to care for the residents in day-to-day operations and in emergencies. This failure could affect all facility occupants. The facility's census was 81.
Record review of the facility's undated Facility Assessment Tool, showed:
- Requirement: nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the type of resources the facility needs to care for their residents;
- Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies;
- Acuity (level of care and services required) of residents' special treatments and conditions and assistance with activities of daily living documentation left blank/uncompleted;
- Staffing plan to ensure sufficient staff to meet the needs of the residents at any given time documentation left blank/uncompleted;
- Physical environment and building needs to ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents documentation left blank/uncompleted
- Each of these documents did not contain the required information to determine how and when the resources available to care for the residents would be used during both day-to-day operations and in emergencies.
During an interview on 12/9/21 at 11:57 A.M. with the Director of Operations and Administrator, the Director of Operations said she would expect the facility to have a facility assessment and the administrator is responsible for that. The Administrator has only been at the facility about two months and has not completed the assessment.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) com...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee made good faith attempts to identify and correct quality deficiencies. The survey team identified quality deficiencies for environment, cardiopulmonary resuscitation (CPR) and quality of care for wounds. This failure had the potential to affect all residents in the facility. The census was 81.
Record review of the facility's undated list of QAPI Committee Members showed:
- Members include the Administrator, Director of Nursing, QAA nurses, Social Worker and Social Services designees, Business Office Manager, Minimum Data Set (MDS: a federally mandated assessment instrument completed by the facility) Coordinator, Housekeeping Supervisor, Dietary Supervisor, Activity Director, Admissions Coordinator, Maintenance Director, Medical Records, Medical Director, Therapy Coordinator, Registered Dietician, Pharmacy Representative, and Lab Representative;
- QAPI meetings held quarterly.
Record review of the facility's undated QAPI Plan tool showed:
- Our mission is to create a culture of ongoing performance improvement to support a life worth living for those entrusted in our care;
- The purpose of QAPI in our facility is to focus on our vision and mission by including all residents, staff, and family members in the performance improvement process to support a care environment that nurtures meaningful relationships;
- We will set short-term goals in quarterly increments to allow review of our progress towards our annual long-term goal. We will continually monitor to sustain the goals we have met;
- A data review will be performed annually.
The facility did not provide documentation of quarterly QAA/QAPI meetings.
During the entrance conference interview on [DATE] at 2:24 P.M., the administrator said she had only been at the facility for two months. The facility has not had any QAPI meetings since she started. The Director of Nursing (DON) started working at the facility [DATE].
During an interview on [DATE] at 4:00 P.M., the Administrator said she has only been at the facility two months so she doesn't know anything about the QAA/QAPI, she doesn't know if they have one. She said the former Administrator would know more.
During an interview on [DATE] at 4:05 P.M., the MDS Coordinator who was the former Administrator said they do have a plan for identified deficiencies, it should be somewhere in the facility. The Medical Director meets quarterly. They try to have meetings every month and quarterly with the Medical Director, but with the pandemic they have met by phone. They do have a plan that attempts to correct deficiencies. There is a policy that describes how the committee will identify and correct identified deficiencies. Everything should be at the facility in a book. The Director of Operations said she will find it and provide it. She, nor the administrator, knows where the book is.
At the time of the survey exit, the facility had not been able to provide the QA book.
During an interview on [DATE] at 11:57 A.M., the Director of Operations said she would expect the facility to have a QAA committee. The Administrator is responsible for that.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have a Quality Assessment and Assurance (QAA) committee in place which meets at least quarterly to develop and implement appropriate plans ...
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Based on interview and record review, the facility failed to have a Quality Assessment and Assurance (QAA) committee in place which meets at least quarterly to develop and implement appropriate plans of action to correct identified quality of care deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility's census was 81.
Record review of the facility's undated list of QAPI (Quality Assurance and Performance Improvement) Committee Members showed:
- Members include the Administrator, Director of Nursing, QAA nurses, Social Worker and Social Services designees, Business Office Manager, Minimum Data Set (MDS: a federally mandated assessment instrument completed by the facility) Coordinator, Housekeeping Supervisor, Dietary Supervisor, Activity Director, Admissions Coordinator, Maintenance Director, Medical Records, Medical Director, Therapy Coordinator, Registered Dietician, Pharmacy Representative, and Lab Representative;
- QAPI meetings held quarterly.
The facility did not provide documentation of quarterly QAA/QAPI meetings.
During an interview on 12/07/21 at 4:00 P.M., the Administrator said she has only been employed at the facility for two months, and did not know if there was a QAA/QAPI committee or when they might hold meetings.
During an interview on 12/07/21 at 4:05 P.M., the MDS Coordinator, who was the former Administrator, said there is a policy that describes who is on the committee, how they gather information and how often they are to meet. The Medical Director is a member and meets with them quarterly. All of the information should be in a book, but he/she did not know where the book is kept.
During an interview on 12/9/21 at 11:57 A.M., the Director of Operations said she would expect the facility to have a QAA committee and the Administrator would be the one responsible for keeping track of the information.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to post the nurse staffing data with all required components in a clear and readable format. The facility's census was 81.
Recor...
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Based on observation, interview, and record review, the facility failed to post the nurse staffing data with all required components in a clear and readable format. The facility's census was 81.
Record review of the facility's policy titled, Posted Nursing Staffing, dated 12/1/18, showed:
- A copy of the nursing staffing information form will be posted daily;
- The facility's charge nurse and/or designee will update the number of Certified Nurse Aides, Nurse Aides, Certified Medication Technicians, Licensed Practical Nurses, and Registered Nurses that are in the facility at the beginning of each shift throughout each 24 hour period;
- The completed copies of the Nursing Staffing Information forms will be maintained in the front office by the Office Manager for a two year period.
Observation of the posted nurse staffing on the bulletin board at the entrance of the 300 hall in the main lobby area showed:
- On 11/29/21 at 2:15 P.M., nurse staffing, incorrectly dated 11/30/21, posted with no census;
- On 11/30/21 at 9:35 A.M., nurse staffing posted with no census;
- On 12/1/21 at 9:11 A.M., nurse staffing posted with no census;
- On 12/7/21 at 12:15 P.M., nurse staffing, incorrectly dated 12/6/21, posted with no census;
- On 12/8/21 at 10:37 A.M., nurse staffing, incorrectly dated 12/6/21, posted with no census.
During an interview on 12/9/21 at 11:57 A.M., the Administrator, Director of Nursing, Infection Preventionist, and Director of Operations said they would expect nurse staffing to be posted daily with the facility census included.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 7 life-threatening violation(s), 2 harm violation(s), $66,532 in fines, Payment denial on record. Review inspection reports carefully.
- • 90 deficiencies on record, including 7 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $66,532 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Estates Of Perryville, Llc, The's CMS Rating?
CMS assigns ESTATES OF PERRYVILLE, LLC, THE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Estates Of Perryville, Llc, The Staffed?
CMS rates ESTATES OF PERRYVILLE, LLC, THE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 53%, compared to the Missouri average of 46%.
What Have Inspectors Found at Estates Of Perryville, Llc, The?
State health inspectors documented 90 deficiencies at ESTATES OF PERRYVILLE, LLC, THE during 2021 to 2025. These included: 7 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 80 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Estates Of Perryville, Llc, The?
ESTATES OF PERRYVILLE, LLC, THE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 156 certified beds and approximately 107 residents (about 69% occupancy), it is a mid-sized facility located in PERRYVILLE, Missouri.
How Does Estates Of Perryville, Llc, The Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, ESTATES OF PERRYVILLE, LLC, THE's overall rating (1 stars) is below the state average of 2.5, staff turnover (53%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Estates Of Perryville, Llc, The?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Estates Of Perryville, Llc, The Safe?
Based on CMS inspection data, ESTATES OF PERRYVILLE, LLC, THE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 7 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Estates Of Perryville, Llc, The Stick Around?
ESTATES OF PERRYVILLE, LLC, THE has a staff turnover rate of 53%, which is 7 percentage points above the Missouri average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Estates Of Perryville, Llc, The Ever Fined?
ESTATES OF PERRYVILLE, LLC, THE has been fined $66,532 across 3 penalty actions. This is above the Missouri average of $33,744. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Estates Of Perryville, Llc, The on Any Federal Watch List?
ESTATES OF PERRYVILLE, LLC, THE 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.