ASPIRE SENIOR LIVING PLEASANT HILL
For profit - Limited Liability company
90 Beds
ASPIRE SENIOR LIVING
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
16/100
#331 of 479 in MO
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Aspire Senior Living Pleasant Hill has received a Trust Grade of F, indicating significant concerns about its overall quality and care standards. Ranking #331 out of 479 facilities in Missouri places it in the bottom half of the state, and #5 out of 8 in Cass County means only three local options are worse. The facility is improving, having reduced its issues from 20 in 2024 to 4 in 2025, but it still faces serious challenges, including a critical incident where staff performed CPR on a resident who had a do not resuscitate order. Staffing is a weakness, reflected in a poor 1 out of 5 rating and less RN coverage than 93% of Missouri facilities, which raises concerns about the quality of care residents receive. Additionally, the facility has incurred fines totaling $14,433, which is average compared to others in the state, but the presence of numerous deficiencies, including unlicensed nursing staff, highlights ongoing issues that families should carefully consider.
- Trust Score
- F
- In Missouri
- #331/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $14,433 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 10 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 59 deficiencies on record. Higher than average. Multiple issues found across inspections.
16/100
Bottom 31%
Review needed
20 → 4 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 20 issues
2025: 4 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 60%
14pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $14,433
Below median ($33,413)
Minor penalties assessed
Chain: ASPIRE SENIOR LIVING
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Missouri average of 48%
The Ugly 59 deficiencies on record
1 life-threatening 1 actual harm
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 ensure staff performed urinary catheter placement according to acce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff performed urinary catheter placement according to acceptable standards of practice for one sampled resident (Resident #1) out of 16 sampled residents resulting in pain and the presence of blood on the resident's bed after Licensed Practical Nurse (LPN) A attempted to insert the urinary catheter. The facility census was 83 residents.
Review of the Facility's Nursing Procedures Manual for Urinary Catheterization revised 3/30/17 showed:
-Catheters were to have been inserted by licensed nurses under the orders of the attending physician.
-The standard of practice did not support routine changing of urinary catheters at any fixed interval.
-The standard for urinary catheters was to change them as needed only.
-The procedure for placing urinary catheters showed that after sterilizing the resident's perineal area (surface area between the thighs extending from the pubic bone to the tail bone), the tip of the urinary catheter tubing was to have been well lubricated up the tube approximately two to two and one-half inches.
-The urinary catheter was to have then been gently inserted into the meatus (external opening of the urinary tract) approximately two to three inches or until urine flowed from the bladder.
-If resistance was continually met, the nurse was not to have forced entry and report the issue to the nursing supervisor.
1. Review of Resident #1's Facility Face Sheet showed the resident was admitted on [DATE] with the following diagnoses:
-Neurocognitive disorder with Lewy Bodies (a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Vancomycin-Resistant Enterococci (VRE-antibiotic resistant bowel infection) of the urine.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 3/12/25 showed he/she was moderately cognitively intact.
Review of the resident's Physician's Order Sheet (POS) dated 5/13/25 showed the resident's Urinary Analysis (UA) came back positive for VRE, therefore the resident required a urinary catheter be placed to contain the urine for isolation purposes to prevent transmission.
Review of the resident's Nurse's Notes dated 5/13/25 at 10:33 P.M., showed:
-The resident told LPN C that LPN A was unable to place the urinary catheter and the resident was still in a lot of pain from it.
-LPN C noted blood in the resident's brief but no visible external injuries.
-An ambulance was called to have the resident taken to the hospital for evaluation and treatment.
-LPN C spoke to the hospital emergency room (ER) nurse who stated they would do a urine test as well as a Computed Tomography (CT- scan, is a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) of the resident's abdomen and pelvis to check for any internal injuries.
Review of LPN C's written statement dated 5/13/25 showed:
-Around 5:30 P.M., LPN C noticed the resident had straight urinary catheter materials in his/her room but no catheter bag so he/she asked the resident if anyone had inserted his/her catheter.
-The resident said no, the nurse had tried but couldn't get it in.
-The resident said the nurse got a little urine in the tube and then left.
-LPN C notified the former DON and Administrator A.
During an interview on 6/3/25 at 3:30 P.M., LPN C said:
-At around 5:30 P.M., he/she noted LPN A coming out of the resident's room.
-He/She knew the resident was to have had a urinary catheter placed so he/she asked the resident if that had been done or not.
-The resident then told him/her that LPN A tried to get the urinary catheter placed but was unsuccessful and left without placing the catheter.
-He/she noted the resident's bed had blood on it near where the catheter would have been placed.
-When he/she asked the resident if LPN A hurt him/her while attempting to place the urinary catheter, the resident said it did hurt.
-If he/she had any issues with inserting a urinary catheter, he/she would have asked for assistance and not force the catheter tubing into the resident.
-If there were continued issues with inserting the urinary catheter, he/she would have notified his/her DON.
Review of the City Police Report for LPN A dated 5/13/25 at 8:11 P.M., showed:
-The resident was located in an ambulance in the facility parking lot awaiting transport to the hospital for further evaluation and treatment.
-The resident said that he/she had received a catheter placement procedure from a nurse.
-The resident stated during the place of the catheter, he/she was subjected to an unusual amount of pain, stating the nurse placed the device then removed it, leaving the room.
-When the resident told the nurse he/she was in pain, the nurse said nothing, turned, leaving the room without replacing the catheter.
- The resident reported the incident to another nurse saying that nurse the nurse hurt me and I am bleeding.
-The resident stated that he/she had catheters placed in the past, including one just placed within the past week, and none had been painful like the last on and none had ever caused him/her to bleed.
-The resident was then transported by ambulance to the hospital for evaluation and treatment.
Review of the resident's Verification of Investigation dated 5/13/25 showed:
-The resident made a statement, He/She hurt me and made me bleed. He/She took my pee and left, after having LPN A insert the resident's urinary catheter.
-The resident was assessed as having been alert and oriented with occasional confusion.
-He/She was frequently incontinent of urine and often refused to allow the staff to assist him/her.
-Upon investigation, it was determined the nurse, LPN A appeared to have been under the influence.
-At that time, LPN A went to the resident's room to perform a urinary catheterization.
-When the resident complained of pain and bleeding from the urinary catheterization by LPN A administration removed the nurse who inserted the urinary catheter from all resident care.
-The resident was sent to the hospital for evaluation of any potential trauma.
-The resident returned from the hospital with no evidence of trauma.
During an interview on 5/27/25 at 1:15 P.M., the resident said:
-He/She did not recall anything about his/her urinary catheter placement.
-He/She did not remember anything about the nurse or the events of 5/13/25.
-He/She stated, My memory isn't so good anymore.
During an interview on 5/27/25 at 4:15 P.M., the DON and Administrator B said:
-They would have expected that given LPN A appeared to be impaired, or at the least, struggling with his/her shift, that he/she would not have attempted to place a urinary catheter in the resident.
-They never wanted any harm to come to a resident at the hand of a staff member.
-They would have expected the employee to have submitted a urine drug screen on site and that as soon as there was sufficient indications from other employees that LPN A was behaving in a manner which could have been reasonable suspicion of working under the influence, LPN A would have been removed from resident care and tested.
-They would have expected if there were issues in inserting the urinary catheter the nurse would have asked for assistance and/or notified the DON.
MO00254215
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
Pharmacy Services
(Tag F0755)
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 keep two residents (Resident #4 and #16), safe from posssible narco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep two residents (Resident #4 and #16), safe from posssible narcotic misappropriation when three milliliters (mls) was missing from Resident #4 and four mls from Resident #16's personal supply out of 16 sampled residents. The facility census was 83 residents.
Review of the facility policy for Inventory Control of Controlled Substances revised 1/1/2013 showed:
-The purpose of the policy was to set forth the procedures for inventory control of controlled substances.
-The facility was to have maintained separate individual controlled substance records on all controlled substances with a potential for abuse or diversion in the form of declining inventory using the Controlled Substances Declining Inventory Record.
-The Inventory Record was to show the resident's name, prescription number, medication name, strength, dosage form, dosage, total quantity received by the facility, the date and time of administration and the signature of the person administering the medication.
-The facility staff was not to enter more than one prescription for a controlled substance medication on each page of a declining inventory record.
-The facility staff was to ensure that the incoming and outgoing nurses count all controlled substances and other medication with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on the Controlled Substance Count Verification/Shift Count Sheet.
-The facility nurses were to reconcile the total number of controlled medications on hand, add newly received medications to the inventory and remove medications that were not completed or discontinued from the inventory.
-The staff nurses were to reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet.
-The facility nurses should routinely reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet, to the medication administration record.
-The facility was to ensure that staff immediately reported suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation, and timely follow-up.
-Upon receipt of such a report, the facility was to have ensured that the appropriate facility personnel confirm the discrepancy and follow facility policy and applicable law regarding documentation of the incident.
-The facility should have also investigated to determine whether a dose was in fact administered and, if so, the reason the administration was not charged we well as whether a dose was refused by a resident.
-A facility representative should have regularly checked the inventory records to reconcile inventory.
-They should have reconciled current and discontinued inventory of controlled substances to the log used in facility's controlled medication inventory system; current inventor to the controlled medication declining inventory record and to the resident's Medication Administration Record (MAR); and, unused controlled substances held in storage awaiting destruction to the declining inventory record.
1. Review of Resident #4's admission Record showed he/she was admitted with the following diagnoses:
-Congestive Heart Failure (CHF- a disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body).
-Dilated Cardiomyopathy (a condition where the heart muscle weakens and the heart's chambers, especially the ventricles, enlarge causing symptoms including shortness of breath).
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).
Review of the resident's May 2025 Physician Order Sheet (POS) showed a physican order for Morphine Sulfate 100/milligrams (mgs) (20 mgs/ml) oral concentrate, 0.25 mls (5 mgs) by mouth or under the tongue every three hours as needed for pain or shortness of air.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) date 5/6/25 showed he/she:
-Was cognitively intact.
-Had no stated pain during the look-back period.
-Had shortness of air with exertion.
During an interview on 5/23/25 at 3:05 P.M., Resident #4 said:
-He/She was doing okay.
-He/She was not aware any Morphine was taken from him/her.
-He/She never missed a dose when asked for Morphine.
-He/She mainly took the Morphine for shortness of breath.
2. Review of Resident #16's Facility Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Pneumonia (inflammation of one or both lungs with consolidation).
-Chronic respiratory failure with hypoxia (a long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, resulting in persistent low blood oxygen levels).
Review of the resident's significant change MDS dated [DATE] showed he/she was severely impaired.
Review of the resident's POS dated 5/20/25 showed he/she no longer had a current order for Morphine.
3. Review of the Facility Verification of Investigation dated 5/13/25 showed:
-LPN A was reported to the former Director of Nursing (DON) as suspected to have been working impaired during his/her shift on 5/13/25.
-Licensed Practical Nurse (LPN) A was informed he/she needed to count the narcotics he/she was responsible for with another nurse.
-Once he/she was told to count the narcotics, he/she handed his/her keys to another nurse and walked away leaving the facility to smoke a cigarette with the Administrator's knowledge.
-The narcotics were immediately recounted by the former DON and two additional nurses and there was a noted discrepancy with the liquid Morphine for two residents, Resident #4 and Resident #16.
-The unaccounted for Morphine was a combined total of 7 mls.
-Resident #16 no longer had an active order for Morphine, and a new prescription was requested from the physician for Resident #4 to allow the facility to replace the resident's Morphine at the facility's cost.
Review of LPN B's written statement dated 5/13/25 showed: on 5/13/25 at around 5:00 P.M., a full narcotics count was completed which showed two resident's Morphine liquid medication counts off.
Review of LPN C's written statement dated 5/13/25 showed:
-He/She and LPN B counted the narcotics and noted that two separate Morphine count numbers were off.
-LPN C notified the former DON, Administrator A and the regional nurse.
Review of the City Police Report for LPN A dated 5/13/25 at 8:11 P.M., showed:
-The offense was listed as Abuse of healthcare recipient-physical, sexual, or emotional harm or injury.
-The Incident Code was listed as stealing.
-Administrator A was then advised there were two liquid Morphine counts off during shift narcotic count.
-Administrator A also told city police that the Morphine bottles that had been tampered with were secured in an office where LPN A could not access them.
-He/she also advised city police there was a total of 6.75 mls missing from the narcotics drawer in the medication cart from the start of the shift to the change of shift.
-There were 3.75 mls missing from one Morphine bottle and 3.0 mls missing from a bottle that had been ordered for Resident #16 and had never been used.
-The seal on the new bottle had been clearly tampered with.
MO00254220
Mar 2025
1 deficiency
CONCERN
(F)
📢 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 F0839
(Tag F0839)
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 Unlicensed Registered Nurse (RN) A had a valid registered nu...
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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 Unlicensed Registered Nurse (RN) A had a valid registered nurse (RN) license in order to provide nursing care to residents such as assessments, wound care, medication administration and all nursing cares allowed by law. This had the potential to affect all residents. The facility census was 78 residents.
On 3/14/25, the Administrator was notified of the past noncompliance which took place over a period of time to include 5/3/24 through 1/30/25. Nurse licensing and state issued identification discrepancies were discovered during audits by the facility Wound Nurse. Education to address the problem was provided to facility staff, including the Director of Nursing (DON), Administrator, Financial Services, and Financial Services Assistant on 2/4/25. The deficiency was corrected on 2/4/25.
Review of Facility assessment dated [DATE] showed:
-Staff competencies for resident population included:
--Abuse training.
--Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) training.
--Behavior management.
-- Post-Traumatic Stress Disorder ((PTSD) is a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it)/Trauma informed care (is an approach to healthcare, social services, and other systems that recognizes the prevalence and impact of trauma and seeks to minimize its harmful effects).
--Wandering and elopement.
--Wander alert system.
--Secure unit.
--Gradual dose reductions.
--Psychoactive (affecting the mind) medications.
-- Abnormal Involuntary Movement Scale ((AIMS) is a standardized tool used to assess and monitor involuntary movements) testing.
-Skills needed for resident population included:
-Medication Administration.
--Oral medication.
-- Intramuscular (IM) the injection of a substance directly into a muscle)/ subcutaneous ((SQ) beneath the skin) /intradermal injection ((ID) injection administered into the dermis, the layer of skin between the epidermis and hypodermis) injections.
--Ophthalmic (eye) medications.
--Inhalers/MDI ' s (meter dose inhalers).
--Topical.
--Otic (ear) medications.
--Intravenous (IV) medications.
--Enteral medications.
--Insulin administration.
---Sliding scale.
--Blood glucose monitoring.
--Anticoagulant (commonly known as a blood thinner, is a chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time) monitoring.
--- Coumadin (a medication used to thin the blood for the prevention of blood clots and stroke).
--- Prothrombin time ((PT) test measures how many seconds it takes for a clot to form in a blood sample) /International normalized ratio ((INR) s the specific blood test used to measure the time it takes for blood to form a blood clot).
---Bleeding precautions.
--Wound Care
---Wound Vac (Negative-pressure wound therapy, also known as a vacuum assisted closure, is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess wound exudate and to promote healing in acute or chronic wounds)/Negative Pressure Wound Therapy (NPWT).
---Dressing changes.
---Wound classification and staging.
---Surgical incision care.
---Suture/staple removal.
---Cast/splint care.
---Adaptive equipment.
--Immunizations.
---Influenza.
---Respiratory syncytial virus (RSV) usually causes mild, cold-like symptoms in most people.
---COVID (a disease caused by the SARS-CoV-2 virus).
---Pneumonia.
---Tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) screening.
--Psychotropic Medication monitoring.
---Gradual dose reduction.
---AIMS testing.
---Behavior management.
--Nutrition Administration/Monitoring
---Weight scales (Patient uses scales standing/lift)
---Dysphagia (inability or difficulty swallowing) symptoms.
---Percutaneous endoscopic gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) tubes
---Gastrostomy tube ((G-tube) is a thin, flexible tube inserted through the abdominal wall directly into the stomach. Its purpose is to provide an alternative route for delivering nutrition, fluids, and medications to patients who cannot eat or drink normally) tube replacement
---Enteral (A form of nutrition that is delivered into the digestive system as a liquid) feeding administration (continuous/bolus)
---Special diets.
---Thickened liquids.
---Adaptive feeding equipment.
---Intravenous (IV) fluids.
--Respiratory (Lung) treatments/monitoring.
---Oxygen administration.
---Oxygen storage.
---Pulse oximetry (measures the amount of oxygen in the blood and the pulse) monitoring.
---Nebulizer (a device for producing a fine spray of liquid) treatments.
---Tracheostomy (surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions) care.
--- Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle).
---Bilevel positive airway pressure (BiPAP) it is a type of ventilator-a device that helps with breathing
---Aspiration (breathing in fluid or foreign material, especially stomach contents or food) precautions.
---Incentive spirometer (a medical device used to encourage deep breathing and improve lung function).
--Investigations and accidents (I&A) prevention/assessment.
---I&A policy.
---I&A completion and documentation
---Care plan interventions.
---Root cause analysis.
-- Dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). monitoring.
---Hemodialysis (process of filtering the blood of a person whose kidneys are not working normally).
--- Peritoneal dialysis (a treatment for kidney failure that uses the lining of the abdomen (peritoneum) as a filter to remove waste products and excess fluid from the blood.
--Gastrointestinal/Urinary.
---Indwelling catheter. (a thin, flexible tube inserted into the urinary bladder through the urethra to collect and drain urine. It remains in place for an extended period, typically days or weeks, to continuously drain urine).
---Suprapubic catheter ((SPC) a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen, used to drain urine when a person cannot urinate on their own or when a urethral catheter is not feasible)
---I&O catheter (a thin, flexible tube inserted into the urethra to drain urine from the bladder and then removed, used for intermittent bladder emptying, often for individuals with urinary retention or difficulty emptying their bladder)
---Incontinent care/peri care.
---Ostomies ((artificial or surgical opening) (Colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen), Jejunostomy (a surgical procedure that creates an opening (stoma) in the jejunum, which is the middle portion of the small intestine)).
---Urostomy.
--Infection Control/Contagious disease management.
---Transmission-based precautions ((TBP) are additional infection control measures implemented in healthcare settings to prevent the spread of infectious diseases that are transmitted through specific routes, such as contact, droplets, or airborne particles) (contact, droplet, airborn)
---Enhanced Barrier Precautions ((EBP) are an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in skilled nursing facilities (SNFs) by expanding the use of gowns and gloves during high-contact resident care activities).
---Personal protective equipment (PPE) don/doff (gown, gloves, mask)
---N95 mask application.
---Equipment cleaning and disinfection.
--Activities of daily living
---Transfers.
---Baths/showers.
---Feeding assistance (calculated fluid intake and percentage of meals consumed).
---Side rails.
---Lifts (total, standing lift).
---Oral hygiene.
---Vital signs measurements (blood pressure, temperature, pulse, and respirations).
---Ambulation.
---Restorative nursing program.
--End of life care.
---Hospice (special kind of care that focuses on a person's quality of life and dignity as they near the end of their life).
---Post-mortem (after death) care.
---Palliative care (specialized form of medical care that focuses on providing relief from pain and other symptoms of serious illnesses).
---Advanced directives (are legal documents that express a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness, injury, or incapacity).
---Pain management.
--Emergency Care.
---Heimlich maneuver (known as abdominal thrusts, is a first-aid procedure used to dislodge a foreign object from a person's airway).
---Cardiopulmonary resuscitation (an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped).
---Crash carts.
---Ambu bag (also known as a bag-valve mask (BVM), is a handheld, self-inflating device used to provide positive pressure ventilation to patients who are not breathing or breathing inadequately, often in emergency situations).
---Significant change in status.
--Intravenous/central lines.
---Midline catheters (type of peripheral intravenous (IV) catheter, longer than a short peripheral IV, typically inserted into a vein in the upper arm, with the tip positioned below the shoulder, but not reaching the central circulation)
---Peripherally inserted central catheter ((PICC) is a long, thin, flexible tube inserted into a vein in the arm and threaded to a large vein near the heart, used for long-term intravenous access and medication administration) lines.
---Peripheral I.V.'s (a small, short, flexible tube inserted into a vein, usually in the hand or arm, to administer fluids, medications, or blood products, and is used for short-term treatments).
---Central lines (known as a central venous catheter (CVC), is a long, thin, flexible tube inserted into a large vein near the heart, used for administering medications, fluids, blood products, and drawing blood, often for long-term or complex treatments).
---Total Parenteral Nutrition ((TPN) (a medical treatment where all necessary nutrients are provided directly into the bloodstream through a catheter. It is used when a patient is unable to receive nutrition through their mouth or digestive tract).
--Orthopedic (bones)/Musculoskeletal (muscles).
---Adaptive equipment (walkers, wheelchairs, canes/crutches)
---Recliners/adaptive seating.
---Positioning devices.
---Physical restraints.
---Splints/braces/immobilizers.
-For any new admission of continuing care for residents with a new diagnosis or profile that required a different type or level of care from that listed above, the condition was reviewed to determine whether it might pose a challenge to the facility in meeting the needs of the resident. The Director of Nursing, or designee, reviewed the medical information for approval of the of the admission or recommendation for continued care.
-The facility had the necessary care and services, equipment, and staff competencies that addressed the current and future needs of the facility.
-Those items included care planning by nursing.
-The facility offered seven days per week wound care by qualified professionals.
-Medication administration all routes.
-Risk assessments (falls, nutrition, elopement, pressure ulcer, etc.).
-Respiratory treatments.
-Weekly skin assessments by qualified nurses.
-Weekday staffing was three Registered Nurses (RN).
-Weekend staffing was two RN's.
1. Review of facility investigation dated 3/11/25 showed:
-Unlicensed RN A was employed at the facility, as a RN, on the following dates 6/6/23-6/16/23; as a Staffing Coordinator (no resident care), and on 5/3/24-1/30/25 as a RN Charge Nurse.
-During a routine audit of employee files, it was discovered that Unlicensed RN A had a different name than that of his/her state issued identification.
-Unlicensed RN A worked in the capacity of a RN and provided skilled nursing care to residents until termination on 1/30/25.
-Residents still in the facility were assessed for any negative outcomes and none were identified.
-Interviewed residents did not voice any concerns with the care provided by the unlicensed staff.
-Unlicensed RN A was suspended on 1/30/25 pending the results of the investigation.
-Unlicensed RN A claimed to not know his/her RN license number.
-Unlicensed RN A did not know when his/her license was renewed because his/her mother did that and paid for his/her license yearly, and that the facility would need to contact his/her mother to find out when the license was renewed.
-Unlicensed RN A then said that his/her mother had forgotten to renew his/her license.
-Unlicensed RN A was tearful and did not realize he/she did not have a current RN license.
-Unlicensed RN A said it was a discrepancy with his/her name and the state licensing board.
-The facility requested him/her to contact the state licensing board and get the matter straightened out and provide them with the necessary documentation.
-Unlicensed RN A claimed to have called the state licensing board and was waiting on a call back.
-The facility requested transcripts from the nursing program and Unlicensed RN A agreed to get them but never produced the transcripts.
-The facility called a neighboring state licensing board and were able to verify that the license number Unlicensed RN A provided to the facility did not match the social security number or date of birth of Unlicensed RN A.
-A search of the state licensing board showed no license for Unlicensed RN A.
-When the facility informed the Unlicensed RN A of this information he/she admitted that they had taken the National Council Licensure Examination (NCLEX) exam for his/her nursing license and provided screen shot of the registration for the exam and when asked the results he/she reported that it was a failing score.
-Unlicensed RN A stated they never retook the test.
-When investigation was completed both state licensing boards were notified.
-A police report was made.
-Root Cause analysis was completed with the findings:
--Upon employment Unlicensed RN A presented themselves as another person with a valid nursing license from a neighboring state.
--The name on the government issued documents did not match the name on the nursing license.
--Facility staff involved in the onboarding process for new employees were re-educated on the verification process when a name on government issued documents does not matched the name on the professional license.
-Reviewed the one-on-one reeducation given to the staff responsible for new hire documentation dated 2/4/25.
Review of police report dated 3/11/25 at 11:32 P.M. showed:
-Police Officer responded for a citizen contact via phone call.
-The citizen identified themselves as the Regional Administrator for the facility
-Regional Administrator stated the following:
--While a routine employee file audit was conducted:
---It was discovered that the name on a RN license did not match the name of other documents used to verify the identity of the employee.
---The employee was suspended, and an internal investigation was started.
---The conclusion of the investigation was that the employee did not have an RN license in any state.
---The license provided belonged to another RN.
---The social security number and date of birth for the RN license did not match the number or date of birth on the government documents.
---When the Regional Administrator confronted the employee about this the employee admitted to finding the license in a similar name to the employee's and used it to obtain employment as a RN.
---Unlicensed RN A had attended a nursing program and registered to the take the NCLEX-RN exam, but was unable provide proof of passing the examination.
-Unlicensed RN A was employed as RN at the facility.
-During the time of employment, Unlicensed RN A was responsible for directly carrying out Physician's orders for a multitude of residents.
-Unlicensed RN A was responsible for completing skilled nursing assessments and oversaw the care provided by other staff.
Review of supplemental police report dated 3/16/25 at 10:21 P.M. showed:
-Police officers arrived at the station and conducted a follow-up interview with unlicensed RN A.
-Unlicensed RN A said that from 6/6/23 to 6/16/23 he/she was not employed as a licensed nurse but as a Staffing Coordinator.
-When asked Unlicensed RN A said he/she had attended two nursing programs.
-Unlicensed RN A was unsure what state had issued his/her nursing license because they had attended school in a neighboring state and lived in another state.
-Unlicensed RN A had taken the NCLEX exam but was unable to recall the location or dates of testing.
-Unlicensed RN A had thought they had passed the NCLEX examination.
-Unlicensed RN A had a Certified Nursing Aide (CNA) license but let it lapse.
-When asked where unlicensed RN A got the other RN license, he/she said that a Staffing Coordinator helped him/her look it up online.
-Unlicensed RN A said he/she never had a physical copy of his/her state nursing license.
-Unlicensed RN A stated he/she knew it was wrong to practice nursing care without a valid license.
During an interview on 3/14/25 at 12:21 P.M. Financial Services said:
-He/She did not hire the nurses.
-He/She was not at the facility when Unlicensed RN A was hired as a RN.
-He/She does not process new hire paperwork.
-If the Human Resources Specialist was out of the office, he/she was educated on the two-step process to verify a license.
-He/she would verify the name on the state issued identification and the nursing license to ensure the names matched.
-Once the facility verified the information it was sent to cooperate office Human Resources for a double check.
During an interview on 3/14/25 at 12:27 P.M. Financial Services Assistant (FSA) said:
-He/She was not at the facility when Unlicensed RN A was hired as a RN.
-The former Staff Development Coordinator was responsible for hiring the unlicensed staff as a RN.
-The former Staff Development Coordinator handled all the new hire paperwork.
-There was no auditing process for new hire paperwork before.
-There was no new hire checklist before.
-The process now for new hire nurses was:
--A new checklist was developed for new hire employees.
--He/She reviews the government paperwork and the nursing license to ensure that the names match.
-The government paperwork and nursing license are kept in a binder together.
-There is a three-folder system now.
-Once he/she has checked and verified the information is correct it is sent to corporate for a double check.
During an interview on 3/14/25 at 12:40 P.M. DON said:
-He/she was not at the facility when Unlicensed RN A was hired as a RN.
-The former Staff Development Coordinator hired Unlicensed RN A as a RN.
-He/She believed Unlicensed RN A was hired because he/she had worked at the facility sometime before.
-The FSA now does the new hire paperwork and verifies nursing license matches government paperwork required for new hire.
-The Administrator and Corporate Human Resources both have verified the information before a job interview was scheduled.
During an interview on 3/14/25 at 12:50 P.M. Administrator said:
-At the time Unlicensed RN A was hired it was the Staff Development Coordinator's responsibility to complete and verify all the new hire paperwork.
-The Staff Development Coordinator quit in September and since that time the FSA has been doing the new hire paperwork.
-Now most of the applications for new nurses come from computer websites.
-He/she then would request the required paperwork and review the paperwork.
-If he/she saw no red flags would schedule and interview and then double check the paperwork to ensure all was correct.
-Once license was verified a job offer would be made after the Corporate double checked all the supplied information.
Review of undated Unlicensed RN A employee file showed:
-A state identification card/non drivers licence in the name of Unlicensed RN A with a same state address on it.
-Social Security card in the name of the Unlicensed RN A .
-A neighboring nursing license with a name that did not match that of Unlicensed RN A's legal documents.
NOTE: Certified letters were mailed on 3/28/25 to Unlicensed RN A and the former Staff Development Coordinator.
An EDL was not referred due to this was forwarded to CMS for potential fraud.
MO00250897
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one sampled resident (Resident #69) when on 12...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one sampled resident (Resident #69) when on 12/27/24 Resident #387 grabbed Resident #69 in the hallway resulting in him/her twisting and causing bruising to the resident's left forearm out of 17 sampled residents. The facility census was 76 residents.
On 1/2/25 the Administrator was notified of Past Non-Compliance which occurred on 12/27/24. Facility training for abuse, neglect, dignity and customer services was completed for all staff 12/28/24 prior to the start of their shift. The deficiency was corrected 12/28/24.
Review of the facility Resident Rights Policy dated 5/1/23 showed:
-Purpose:
--This policy is concerned with all incidents and accidents involving residents.
--All of our residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property.
--Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish.
1. Review of Resident #387's Face Sheet showed the resident was admitted on [DATE], with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone or posture), seizures, intellectual disabilities, and brain disorder.
Review of Resident #387's admission Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/25/24, showed the resident:
-Had memory problems with severe cognitive incapacity.
-Did not have any behavioral symptoms, mood, depression or anxiety.
-Needed moderate to maximum assistance with bathing, dressing, toileting, mobility and used a wheelchair for ambulation.
Review of Resident #387's Care Plan dated 11/21/24, showed the resident had an intellectual disability, memory and recall problems and difficulty making himself/herself understood. There was no documentation showing the resident had any aggressive behaviors. Interventions showed staff would:
-Maintain a structured environment and provide instruction at the resident's level of understanding.
-Provide personal space.
-Provide a daily tasks activity schedule.
-Develop personal supports, family is very supportive.
-Redirect the resident when entering unsafe areas.
-Follow up with facility representatives to ensure recommendations are fully implemented.
Review of Resident #69's Face Sheet showed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, depression, anxiety, pain and respiratory disease.
Review of Resident #69's quarterly MDS dated [DATE], showed:
-He/she had significant cognitive impairment.
-He/she had no behavioral issues during the look back period but showed signs/symptoms of depression.
-He/she needed partial to moderate assistance with bathing, dressing, toileting, mobility and used a wheelchair for ambulation.
Review of Resident #387's Nursing Notes dated 12/27/24 at 3:10 P.M. showed he/she had an altercation which was witnessed by staff involving this resident reaching out and grabbing another resident's arm causing bruising to occur.
Review of Resident #69's Nursing Notes dated 12/27/24 showed:
-He/she had a resident to resident incident where he/she was not the aggressor. A skin assessment was completed on the resident and the resident sustained two dark purple bruises to his/her left forearm that measured 6 centimeters (cm) length by 6.5 cm width, and 1.5 cm length by 2 cm width. The resident denied any complaint of pain or discomfort.
Review of the facility investigation report dated 12/27/24 showed:
-Staff reported Resident #387 was seen holding Resident #69's arm. Staff immediately separated the residents and the resident was placed on one to one monitoring.
-Resident interview summary showed the facility staff was unable to successfully interview the residents to find out what occurred due to both of the resident's dementia and ability to recall the incident.
-Resident #69 said they were friends and it was all in good fun.
Observation and interview on 12/31/24 at 9:35 A.M., showed Resident #69's was laying in his/her bed awake and wearing oxygen. On the resident's left forearm were two fading purplish bruises. The resident said:
-He/She felt safe in the facility and was not afraid of any residents.
-He/She was not in any pain or discomfort.
During an interview on 12/31/24 at 11:44 A.M. Certified Medication Technician (CMT) A said:
-He/She was working and observed the resident incident on 12/27/24 that was after breakfast when residents were exiting the dining area.
-Resident #387 was sitting in his/her wheelchair in the hallway and was tapping residents on the arm or shoulder as they went by.
-Resident #387 was swinging his/her arms so he/she told the resident he/she was going to move him/her over since he/she was blocking the entryway to the dining area, and moved the resident over out of the middle of the entryway.
-The resident continued to swing his/her arms and hit a resident. The resident became agitated, so he/she moved Resident #387 down the hallway toward his/her room, but the resident did not want to go into his/her room and stayed outside of his/her room.
-A few minutes later he/she saw the resident by the nursing station where Resident #69 was sitting and he/she heard Resident #69 yell, stop that hurt and he/she went to see what occurred and saw Resident #387 twisting Resident #69's left forearm.
During an interview on 12/31/24 at 2:35 P.M., showed Licensed Practical Nurse (LPN) A said:
-He/She was working on 12/27/24 and both residents were outside of the 200 hall when he/she heard Resident #67 say ouch, you're hurting me.
-He/She looked up and saw Resident #387 was holding Resident #69's left arm.
-There was another nursing staff that was already separating the residents and had Resident #69 at the nursing station.
-Resident #387 was headed back down the 200 hallway.
-He/She completed a skin assessment on Resident #67 and saw the bruising on his/her left forearm and documented it in his/her medical record. The Nursing Assistant (NA) went to inform the Administrator and DON.
During an interview on 1/2/25 at 9:03 A.M., NA A said:
-Usually Resident #387 does not become aggressive unless residents or staff, are trying to pass him/her in the hall or in the dining area (anywhere there is a group of people).
-Resident #387 will deliberately sit in the pathway so that residents cannot get around him/her and will refuse to move when they ask him/her to move.
-Staff will then have to assist and move Resident #387 and if the residents or staff try to move him to get around him/her, Resident #387 will become physically aggressive.
-Resident #387 has hit at him/her when he/she has tried to get him/her to move to the side so that a resident could pass in the hallway.
During an interview on 12/31/24 at 1:50 P.M., the Director of Nursing (DON) said:
-On 12/27/24 he/she was working and received a report that Resident #387 and Resident #69 were passing each other in the hall and they were tapping each other on the arm and Resident #387 grabbed Resident #69's arm and twisted it.
-Nursing staff stepped in and separated the residents and a skin assessment was performed on Resident #69 and showed bruising on his/her arm.
-Resident #387 does not like for people to be in his/her space and does not like to be in groups of people.
-Resident #387 will place himself/herself in the middle of the hallway when other residents and staff have to try to get by him/her.
-Resident #387 does not like to be moved.
-After the incident occurred, he/she tried to interview Resident #387 and he/she did not think he/she understood what he/she was asking. He/She also interviewed Resident #69 and he/she said that it was all in good fun and that he/she did not think Resident #387 was trying to harm him/her.
-Since this incident, Resident #387 has had physical aggression towards staff and another resident.
During an interview on 12/31/24 at 2:52 P.M., the Administrator said:
-He/She was in the facility on 12/27/24 and the DON told him/her about the incident between Resident #387 and Resident #67.
-He/She thought that the nursing staff that initially moved Resident #387 out of the hallway was what made Resident #387 agitated initially. He/She said he/she tried to speak with Resident #387 and he/she did not respond at that time.
-A couple hours later, the DON said the residents were on the 200 hall and staff saw Resident #387 grab Resident #69's arm causing bruising. Staff separated the residents.
MO00247157
Nov 2024
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was included on his/her care plan meetings and ca...
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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 a resident was included on his/her care plan meetings and care plan meeting invitations for two sampled residents (Resident #59 and #75) out of 22 sampled residents. The facility census was 80 residents.
Review of the policy Person Centered Care Plans effective date 8/15/18 showed:
-Preparation for Care Plan Committee Meetings:
--The Registered Nurse or other designee should provide a list of resident/guest(s) names, dates, and times for care plan meetings two weeks in advance to other team members. This list also includes information as to the type of care plan review for each resident/guest, admission, quarterly, annual, or significant change in status reviews.
--The Social Service Director (SSD, or other designee, should inform the resident/guest and families of the scheduled meeting by mailing the Notice of Schedule Plan of Care Conference to family members or legal representatives, as meeting notice. Family members and legal representatives should only be invited to attend, when permitted by the resident/guest, or when the party is legally responsible for making the health care decisions for the resident/guest.
--The Interdisciplinary team (IDT) members should prepare for the care plan meeting by completing an assessment of the resident/guest and initiating care plan entries for problems or concerns related to the resident/guest as appropriate.
-Conducting the Person-Centered Care Plan Meeting:
--The team, including the resident/guest and their desired representatives, when possible, should present findings from assessments, using information from the Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan and discuss suggested new goals or approaches, as appropriate. Existing goals and approaches should be reviewed and revised as needed. Any input gained from the resident/guest should be recorded in the plan of care and the resident/guest participation should be recorded in the electronic medical record (EMR).
--When the resident/guest is unable to attend, but able to comprehend the plan of care, a review of the plan should be conducted by the care plan designee. The resident/guest participation should be recorded in the EMR.
--The care plan team should develop a comprehensive care plan for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s)medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and the resident/guest(s) goals and preferences, future discharge.
--Each participant in the care plan meeting should document their involvement.
1. Review of Resident #59's undated Face Sheet showed his/her most recent admission was 12/14/23.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/7/24 showed the resident had some cognitive impairment that needed support.
During an interview on 10/28/24 at 8:28 A.M. the resident said he/she was not aware of care plan meetings or involved in the setting of goals, and had not been invited to care plan meetings. Resident had not seen his/her care plan. He/She had two sons that were retired but did not provide help. He/She would like to participate in the care plan process.
Review of the resident's care plan meeting invitation binder on 10/30/24 at 11:06 A.M. showed:
-Care plan meeting invitations for 5/28/24, 8/7/24, and 11/13/24 were addressed to the resident's family member. No care plan meeting invitations were addressed to the resident.
-No documentation the resident was presented a copy of these invitations to his/her care plan meetings.
-No documentation of who attended the care plan meetings.
2. Review of Resident #75's undated Face Sheet showed his/her most recent admission was 4/7/24.
Review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact.
During an interview on 10/28/24 at 11:50 A.M. the resident said he/she had not been informed of care plan meetings, had not been invited to care plan meetings, or involved in the setting of goals but would like to be involved. He/She had not seen his/her individualized care plan.
Review of the resident's care plan meeting invitation binder on 10/30/24 at 8:43 A.M. showed:
-Care plan meeting invitations for 6/14/24, 7/31/24, and 10/10/24 were addressed to the resident's family member. No care plan meeting invitations were addressed to the resident.
-No documentation the resident was presented a copy of these invitations to his/her care plan meetings.
-No documentation of who attended the care plan meetings.
3. During an interview on 10/30/24 at 11:06 A.M. the SSD said:
-Care plan meeting invitations were sent to the family.
-Care plan meeting invitations are not sent out or given to the residents.
-The Interdisciplinary Team (IDT) would speak to the resident to ask if there were concerns.
-A care plan conference form would be signed to document the meeting by all who attended the meeting.
-A care plan conference form was not located for Resident #59 or #75.
During an interview on 11/01/24 at 08:43 AM. the MDS nurse said:
-The Social Service Director would send the care plan meeting invitations.
-The facility tries to include the resident and/or the responsible party.
-The care plan meeting was attended by the MDS nurse, SSD and Business Office Manager (BOM), Activities Director (AD) would be there if there were an activity concern. The dietary manager was new and not attending at this time.
-The care plan meetings were to be documented in the chart.
-The SSD usually made a note documenting the care plan meeting.
-He/She felt a skilled resident was involved in goal setting.
-The IDT would ask a long-term care resident if they had concerns or wanted something different.
-He/She reviewed the baseline care plan with new residents.
-He/She did not review the comprehensive care plans with residents.
During an interview on 11/01/24 at 11:31 A.M. the Director of Nursing (DON) said:
-He/She expected residents to participate in the development and implementation of the person-centered care plan.
-He/She expected residents to be involved in the establishment of goals.
-He/She expected the residents were able to review their care plans.
-He/She expected a member of the IDT would document the care plan meeting in the clinical chart. This was usually the SSD.
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 correct code status was in place for one sampled residen...
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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 correct code status was in place for one sampled resident (Resident #28) out of 22 sampled residents. The facility census was 80 residents.
A policy related to advance directives was requested and was not received by the facility.
1. Review of Resident #28's face sheet showed he/she admitted to the facility on [DATE] with a diagnosis of Encounter for Other Orthopedic Aftercare.
NOTE: The face sheet also showed that the resident did not have an advance directive or code status in place.
Review of the resident's Physician Order Sheet (POS) dated [DATE] showed no order for an advance directive or code status.
Review of the resident's care plan dated [DATE] showed the resident's advance directive or code status was not in the care plan.
Review off the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed the resident was cognitively intact.
Review of the resident's Electronic Medical Record (EMR) on [DATE] at 10:34 A.M. showed the resident did not have an advance directive in place and no documentation of the resident's desire for a Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) code status.
Review of the resident's paper chart on [DATE] at 2:22 P.M. showed the resident did not have an advance directive in place and no documentation of the resident's desire for a DNR code status.
During an interview on [DATE] at 9:34 A.M. the resident said he/she had a code status of DNR.
During an interview on [DATE] at 9:35 A.M. Family Member A said:
-The resident was a DNR.
-The resident's DNR status should be in the facility records.
During an interview on [DATE] at 8:59 A.M. the Social Services Designee (SSD) said the resident was a full code, so the facility did not have any record of the resident's advance directive or desire for a DNR code status.
During an interview on [DATE] at 8:03 A.M. Certified Nursing Assistant (CNA) A said:
-The facility usually received a resident's advance directive and code status upon admission.
-The nurses were responsible for ensuring the completion of the advance directive.
-If a resident stated that they were supposed to be a DNR, then he/she would get the nurse or SSD.
-A resident's advance directive could be found in the EMR or in a paper chart.
-If a resident is a DNR then there should be an order in place.
-He/She thought the resident was a full code (indicates the healthcare team should perform CardioPulmonary Resuscitation (CPR) - if needed).
-The resident's advance directive and code status should be on his/her care plan.
-He/She was unaware that the resident was supposed to be a DNR.
During an interview on [DATE] at 8:14 A.M. Registered Nurse (RN) A said:
-Nurses were responsible for ensuring the resident's correct advance directive and code status was in place upon admission.
-A resident's advance directive could be found in the EMR or in a paper chart.
-If a resident requested to be a DNR then he/she would discuss his/her code status with the resident to ensure that is what the resident wanted and get an order from the doctor.
-An order should be in place for a resident who is a DNR.
-He/She thought the resident was a full code.
-If the face sheet showed There are no Advance Directives selected for this resident then that indicated the resident's code status was not in the EMR.
-He/She was unaware that the resident did not have an advance directive in place and that the resident was supposed to be a DNR.
-A resident's advance directive and code status should be on his/her care plan.
During an interview on [DATE] at 11:36 A.M. the Director of Nursing (DON) said:
-Nurses were responsible for obtaining a resident's advance directive and code status upon admission.
-Advance directives and code status should be on all resident care plans.
-If a resident wanted to be a DNR, then he/she would expect the nurses to ensure the resident could make his/her own decisions, get an order, and ensure the appropriate documentation was in place.
-There was a banner in the facility's electronic medical record system that indicated what a resident's code status was.
-There would only need to be an order in place in the resident's POS if the resident was a DNR.
-He/She thought the resident was a full code.
-He/She was unaware that the resident's advance directive had not been completed and that the resident was supposed to be a DNR.
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 physician when medication could not be obtained from the...
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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 physician when medication could not be obtained from the pharmacy for one sampled resident (Resident #61) out of 22 sampled residents. The facility census was 80 residents.
Review of the facility Medication Shortages/Unavailable Medications, dated 1/1/13, showed:
-When the facility discovers it has an inadequate supply of medication to administer to a resident then the facility staff should immediately initiate action to obtain the medication from the pharmacy.
-If facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, facility nurse should notify the nursing supervisor and contact facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage.
1. Review of Resident #61's Face Sheet showed the resident was admitted on [DATE] with the following diagnoses:
-Alcohol-induced chronic pancreatitis (inflammation of the pancreas).
-Alcohol abuse with other-induced disorder.
Review of the resident's Physician Order Sheet (POS) dated 9/19/24 showed the following physician's ordered medication:
-Acamprosate 333 milligrams (mg) two tablets three times daily at 9:00 A.M., 3:00 P.M. and 9:00 P.M. by mouth for alcohol abuse with other alcohol-induced disorder.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/26/24 showed the resident was cognitively intact.
Review of the resident's Medication Administration Record (MAR) dated 10/2024 showed:
-Acamprosate 333 mg two tablets three times daily at 9:00 A.M., 3:00 P.M. and 9:00 P.M. by mouth for alcohol abuse with other alcohol-induced disorder.
-The medication was not administered by staff a total of 21 days out of 31 days in this month.
-The staff documented the medication was unavailable from the pharmacy.
-No documentation the resident's physician wasn notified the medication was not available and not administered to the resident.
Review of the resident's Care Plan, dated 10/2/24, showed:
-The resident had an alcohol induced chronic Pancreatitis.
-The staff were to monitor and record any complaints of pain: character, onset, pattern, location, severity, duration, aggravating factors, and alleviating factors.
-The staff were to monitor and record any non-verbal signs of pain: guarding, moaning, restlessness, grimacing, diaphoresis, and withdrawals.
During an interview on 10/31/24 at 2:05 P.M., the resident said:
-He/She did not need the Acamprosate medication and he/she did not want to take it.
-He/She had no side effects of alcohol withdrawal by not taking the medication.
During an interview on 10/31/24 at 2:21 P.M., Licensed Practical Nurse (LPN) C said:
-If the medication became unavailable then the Certified Medication Technician (CMT) or a nurse could click the resupply button in the resident's electronic record and re-order it from the pharmacy.
-The CMT or the nurse could call the pharmacy to see how long it would take to get the medicine.
-The CMT should notify the nurse so the nurse could call and notify the physician immediately when it cannot be filled by the pharmacy.
-He/She was not told by any CMTs the medication had not been received by the pharmacy.
During an interview on 11/1/24 at 8:55 A.M., CMT A said:
-If a medication was unavailable then he/she would notify the charge nurse.
-The charge nurse was responsible for notifying the physician.
During an interview on 11/1/24 at 11:36 A.M., the Director of Nursing (DON), Regional Nurse Consultant (RNC), and Regional Quality Assurance Nurse (RQAN), the DON said:
-He/She expected the charge nurse would be notified that the medication had not been received by the pharmacy.
-He/She would contact the pharmacy about obtaining the resident's medication.
-He/She would not let a resident go more than one day without a medication.
-He/She expected the charge nurse to call and notify the physician if a medication was not available from the pharmacy.
-He/She was unaware the resident had not received his/her medication.
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** 2. Review of Resident #5's annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #5's annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 10/11/24 showed the resident had moderately impaired cognition.
Review of the resident's Electronic Medical Record (EMR) showed:
-The resident had been hospitalized from [DATE] to 7/9/24.
-The resident had been hospitalized from [DATE] to 7/19/24.
-No indication that the resident's Designated Power of Attorney (DPOA) had been enacted.
-No documentation of a Bed Hold form was completed or signed for either discharge.
During an interview on 10/30/24 at 12:21 P.M., the DON said:
-He/She could not find the resident's physical bed hold forms, but there were notes related to the bed hold in the resident's EMR.
-There should have been a physical bed hold form completed for the resident for both hospitalizations.
-Normally the Social Services Designee (SSD) would follow-up the next day following a resident hospitalization to ensure completion of the bed hold form.
During an interview on 10/30/24 at 1:05 P.M. the SSD said he/she did not have copies of the resident's bed hold forms from the last two hospitalizations.
3. During an interview on 11/1/24 at 8:03 A.M. Certified Nursing Assistant (CNA) A said the SSD was responsible for completing the bed hold forms.
During an interview on 11/1/24 at 8:17 A.M. Registered Nurse (RN) A said:
-The charge nurses were responsible for giving the bed hold forms to residents.
-He/She was unsure of who ensured completion of the bed hold forms.
-He/She had not been trained on the facility's bed hold process.
During an interview on 11/1/24 at 9:17 A.M. the SSD said:
-He/She had not followed up on the resident's bed hold forms.
-He/She was not always good about completing the follow-up of the bed hold forms.
-Some of the nurses were good about completing the bed hold forms and bringing them to him/her and some were not.
During an interview on 11/1/24 at 11:36 A.M. the DON and the Regional Corporate Nurse said:
-The charge nurses were responsible for completing the bed hold forms.
-If the resident is not able to sign the bed hold upon leaving the facility, the nurse should complete the top of the form and send it with the resident to the hospital.
-He/She did not know if they keep a copy of the bed hold form and the Social Service Designee usually was responsible for ensuring the completion of the bed hold.
-If the resident was not able to sign the Bed Hold, he/she would expect the Social Services Designee to notify the responsible party of the bed hold and document their response in the resident's medical record.
-The bed holds had not been completed for Resident #5 because his/her family had declined the bed hold.
During an interview on 11/1/24 at 12:15 P.M. the DON said Resident #5 would be the person that would decline the bed hold and not his/her family.
Based on record review and interview, the facility failed to ensure the resident or resident representative was provided with the bed hold policy or educated on the bed hold policy when the resident was discharged to the hospital in a timely manner for two sampled residents (Resident #8 and #5) out of 22 sampled residents. The facility census was 80 residents.
Review of the facility Transfer/Discharge and Therapeutic Leave policy and procedure updated June 26, 2019, showed:
-A copy of the resident bed hold and admission policies/transfer to the hospital should be provided upon transfer by the assigned nurse to the resident or responsible party.
1. Review of Resident #8's Face Sheet showed the resident was initially admitted on [DATE].
Review of the resident's Nursing Notes showed:
-10/26/24 at 11:19 A.M., showed the physician gave orders to send the resident to the hospital for further evaluation. The resident was unable to sign the bed hold. The nurse called the resident's responsible party again to notify of the resident being sent to the hospital. Nursing staff also notified the Director of Nursing (DON).
Review of the resident's Electronic Medical Record showed there was no documentation showing the resident's Bed Hold form was completed or signed. The Bed Hold form was not in the electronic record or in the resident's paper chart. There was no documentation showing the facility sent the resident's bed hold document to the resident's responsible party or if he/she was informed/educated on the bed hold agreement.
During an interview on 10/31/24 at 2:32 P.M., the Administrator said:
-When the resident went to the hospital, he/she was unable to sign the bed hold form.
-They did not send the bed hold to the resident's responsible party.
-He/She was unable to find the bed hold document for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide an ongoing, person-centered activities program based on care planned and assessed resident interests and abilities in ...
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Based on observation, interview and record review, the facility failed to provide an ongoing, person-centered activities program based on care planned and assessed resident interests and abilities in order to meet the interests and support a residents physical and psychosocial wellbeing for one of 22 sampled residents (Resident #25). The facility census was 80 residents.
Review of a facility policy titled Delegation of Activity Program Duties, dated 3/1/08, showed:
-The facility was to provide an ongoing activities program designed to meet the physical, mental and psychosocial wellbeing of each resident.
-The activities program should have occurred within the context of each resident's comprehensive assessment and care plan.
1. Review of Resident 25's face sheet, dated 6/20/24, showed:
-An admission date of 6/14/24.
-Diagnoses of Down Syndrome (a genetic chromosomal disorder causing developmental and intellectual delays) and a cognitive communication deficit.
Review of the resident's facility Activity Assessment, completed 6/14/24, showed:
-Activity interests of games, socialization, one-on-one activities, cognitive learning, arts and crafts, music, and exercise.
-Goals of attending at least three activities weekly.
-Interventions including providing reminders and assistance for activities and identifying activities suited for the resident's needs.
Review of the resident's Care Plan, dated 9/17/24, lacked information about the resident's preferred activities, activity goals and activity interventions.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated comprehensive assessment conducted by the facility to determine the needs of the resident) dated 10/1/24, showed the resident:
-Rarely or never understood others or was able to make themselves understood.
-Had severely impaired decision-making capabilities.
-Preferred to listen to music, do things with groups of people, participate in favorite activities, and spend time outdoors.
Review of a provided Point of Care History Report for activity participation for the month of 10/24 showed the resident participated in activities on two days, 10/9/24 and 10/29/24.
Observation on 10/28/24 at 8:31 A.M., showed the resident sitting in a chair near the nurse's station making non-lexical vocalizations (sounds that do not form words) and rubbing his/her legs repeatedly. Another unknown resident was attempting to comfort the resident. A bedside table with colored pencils and a coloring sheet was nearby but was not offered to the resident by staff. The resident was not invited to or assisted to participate in activities offered to other residents was made on 10/28/24.
Observation on 10/29/24 at 8:37 A.M., showed the resident was sitting in a chair near the nurse's station making non-lexical vocalizations and looking down at the floor.
Observation on 10/30/24 at 9:46 A.M., showed the resident was taken to a community movie. The resident was observed rubbing his/her legs repeatedly and looking at the floor during the film. Staff were in the room during the movie, no observations of staff interacting with the resident during this activity.
During an interview on 10/31/24 at 1:30 P.M., the resident's family member said he/she has never seen the resident participating in activities at the facility and that the resident receives minimal mental or physical stimulation.
During an interview on 10/31/24 at 1:45 P.M., Certified Medication Technician (CMT) B said he/she was unaware what activities the resident enjoyed but the resident had fidget toys and coloring items that were given to him/her to use.
During observations on the day shift from 10/28/24 to 11/1/24, staff were not observed offering the resident any items for recreational use.
During an interview on 11/1/24 at 8:27 A.M., the Activities Director said:
-He/She completed an activity assessment to determine what residents enjoyed doing.
-The resident could come to activities every once in a while, otherwise he/she would bring the resident a fidget toy to use.
-He/She would expect staff to ensure the resident has something to occupy his/her time throughout the day and not sit in a chair near the nurse's station when the resident cannot participate in the planned activity.
During an interview on 11/1/24 at 11:46 A.M., the Director of Nursing (DON) said:
-He/She would expect staff to assess and offer a resident with appropriate activities that offer mental and physical stimulation.
-He/She would expect staff to have offered the resident more than two activities in a month span.
-He/She would expect individualized activities to be offered to the resident throughout the day if there were group activities he/she couldn't participate in.
-Activity preferences should have been care planned.
-The MDS Coordinator was responsible for ensuring the residents care plan was complete and accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure to have a comprehensive physician's order for colostomy (or ostomy is a surgical procedure that creates an opening in t...
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Based on observation, interview and record review, the facility failed to ensure to have a comprehensive physician's order for colostomy (or ostomy is a surgical procedure that creates an opening in the large intestine, or colon, through the abdominal wall. The opening, called a stoma, allows stool to drain into a bag or pouch attached to the abdomen) care to include type and size of ostomy supplies needed, failed to have a comprehensive care plan for colostomy care and type of supplies needed for one sampled resident (Resident #3) out of 22 sampled residents. The facility census was 80 residents.
Review of the facility's Colostomy Care policy dated 10/1/10 showed:
-Care of the colostomy site helps prevent skin irritation around the sire and leakage of the drainage bag.
1. Review of of Resident #3's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/29/24 showed:
-Was cognitively intact, able to make his/her needs and wants known.
-Had a colostomy upon admission.
Review of the resident's care plan revised on 9/12/24 showed:
-The resident had potential complication for his/her colostomy.
-Care staff were to change colostomy pouch and wafer (is a skin barrier piece of the pouching system that sticks to skin around the stoma to attach the collection pouch) per schedule and as needed.
-Care staff were to empty /rinse colostomy collection pouch as needed.
-Provide colostomy care per schedule.
-NOTE: No documentation on the type ostomy system needed or size wafer needed.
Review of the resident Physician order Sheet (POS) 9/29/24 to 10/29/24 showed:
-Nursing staff were provided routine Colostomy care every shift. Order was dated 8/5/24.
-Note: Did not have detail order for colostomy to include monitoring, when to change the colostomy pouch and wafer, the care of stoma, size of wafer and type collection bag required (These can be one-piece or two-piece systems).
Review of the resident's Medication Administration Record (MAR) 10/1/24 to 10/29/24 showed:
-Physician order for nursing staff were provided routine Colostomy care every shift:
-Had nursing initial of care provided each shift.
-Note: No specific detail order or documentation related to monitoring of colostomy site and type and size of supplies required.
Observation on 10/28/24 at 8:28 A.M., the resident showed had a colostomy located on left lower stomach area.
Observation on 10/29/24 at 11:00 A.M., of the resident wound showed:
-The colostomy collection pouch had loose brownish green stool.
-Wound Nurse said the resident had colostomy due to placement of his/her wounds.
During an interview on 11/1/24 at 8:40 A.M., Certified Nursing Assistant (CNA) E said:
-The resident's colostomy care he/she would clean area and change bag and/or wafer as needed.
-He/She would use a tape measure to measure the stoma for the size opening of the wafer needed to be and cut to fit.
-Nursing would be responsible for ensure to have physician orders for the care and monitoring of the resident colostomy.
-He/She had not cared for the resident colostomy, was not sure type or kind of colostomy the resident had.
During an interview on 11/1/24 at 8:46 A.M., CNA B said:
-The nursing staff would be responsible for replace the resident's colostomy wafer. The CNA would then clean and empty the collection pouch as needed.
-He/She was not sure were to find documentation on type or size of supplies needed for the resident colostomy.
Review of the resident's medical record on 11/01/24 at 9:02 A.M., with Registered Nurse (RN) B showed:
-The resident POS did not have a detail colostomy's order to include the type and size colostomy supplies needed or when to change colostomy wafer and collection pouch.
-The resident's care plan should include how to care for colostomy site and supplies required.
-He/She would expect to have detail physician order for colostomy care and monitoring.
During an interview on 11/01/24 at 11:03 A.M., MDS Coordinator said:
-Would expect to have physician order for the resident colostomy and a comprehensive care plan.
-He/She would be responsible for the review and updating care plan as needed.
-He/She would review the resident's physician order and nursing assessments to be able to complete or update care plans.
During interview on 11/1/24 at 11:36 A.M., Director of Nursing (DON) said:
-He/She would expect to have a comprehensive physician order for a resident with colostomy.
-The physician order should include but not limited: the monitoring of the stoma site, size or type of colostomy supplies needed and when to change colostomy wafer and collection bag.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure appropriate care for one sampled resident (Resident #60) with a Percutaneous Endoscopic Gastronomy (PEG) tube (a tube ...
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Based on observation, interview, and record review, the facility failed to ensure appropriate care for one sampled resident (Resident #60) with a Percutaneous Endoscopic Gastronomy (PEG) tube (a tube that is passed into a person's stomach through the abdominal wall, most commonly used to provide a means of feeding when oral intake is not adequate) out of 22 sampled residents. The facility census was 80 residents.
Review of the facility's policy titled Tube Feeding-Kangaroo E-Pump dated 2/1/18 showed:
-Staff were expected to label the feeding formula including rate, time, and initials.
-Staff were expected to label the flush bag with the date, time, and initial amount of water.
-Staff were expected to follow the manufacturer guidelines related to hang times for the tube feeding.
1. Review of Resident #60's face sheet showed he/she admitted to the facility with the following diagnosis:
-Gastrostomy Status.
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/19/24 showed:
-The resident was non-verbal and could not make himself/herself understood.
-The resident received tube feeding.
-The resident received 51% or more of his/her daily nutrition through tube feeding.
Review of the resident's Physician Order Sheet (POS) dated October 2024 showed:
-Tube feeding per pump pole flush and feed, Jevity 1.2 ( a high-protein, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 55 milliliters (ml) per hour to equal 1495 ml for 23 hours/ flush set at 100 ml for 23 hours.
-An order for the staff to ensure the resident's head of bed (HOB) was elevated to 45 degrees at all times due to tube feeding.
Observation on 10/28/24 at 11:01 A.M. of the resident showed:
-The resident's HOB was at approximately 30 degrees.
-The resident's water flush bag was not labeled.
Observation on 10/29/24 at 8:47 A.M. of the resident showed:
-The resident's HOB was at approximately 30 degrees.
-The resident's tube feeding was not labeled with a start time.
-The resident's water flush bag was not labeled.
Observation on 10/29/24 at 12:03 P.M. of the resident showed the resident's HOB was at approximately 30 degrees.
Observation on 10/30/24 at 8:56 A.M. of the resident showed:
-The resident's HOB was at approximately 30 degrees.
-The resident's water flush bag was not labeled.
Observation on 10/31/24 at 8:43 A.M. of the resident showed:
-The resident's HOB was at approximately 30 degrees.
-The resident's water flush bag was not labeled.
During an interview on 11/1/24 at 8:03 A.M. Certified Nursing Assistant (CNA) A said resident's who have tube feeding running should have their HOB elevated to 30 degrees.
During an interview on 11/1/24 at 8:19 A.M. Registered Nurse (RN) A said:
-When tube feeding was hung the bottle should be labeled with name, date, and volume.
-He/She was unsure if the water flush bag needed to be labeled.
-If he/she were to walk into a resident's room with tube feeding and the bottle was not labeled appropriately, then he/she would hang a new bottle of tube feeding.
-He/She was unsure of the resident's order for positioning.
-He/She was unsure if the facility had a specific policy related to tube feeding HOB positioning, but resident's HOB needed to be positioned at least at 30 degrees.
-If the resident's order stated that the resident's HOB needed to be at 45 degrees, then that is how the resident's HOB should be positioned.
-He/She had not been into the resident's room at that point in time and he/she was unsure how the resident had been currently positioned.
During an interview on 11/1/24 at 11:36 A.M. the Director of Nursing (DON) said:
-He/She expected the tube feeding set to be labeled with the date and start time.
-He/She expected staff to change out the tube feeding set if the tube feeding set was not labeled appropriately.
-Resident's who have continuous tube feeding should have their HOB elevated at 45 degrees.
-He/She expected staff to follow the physician's order for how the resident's HOB should be set at.
-The resident's order needed to be updated to show the HOB could be between 30 to 45 degrees.
-The nurses were responsible for ensuring the correct HOB positioning of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #75's undated Face Sheet showed he/she was admitted [DATE] with the following diagnoses:
-End state renal ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #75's undated Face Sheet showed he/she was admitted [DATE] with the following diagnoses:
-End state renal disease (ESRD - the final, permanent stage of chronic kidney disease where the kidney function has declined to the point that the kidneys can no longer function on their own).
-Hypertensive chronic kidney disease with stage 4 chronic kidney disease or end stage renal disease.
-Dependence on renal dialysis.
Review of resident's quarterly MDS dated [DATE] showed he/she had intact cognition and received dialysis.
Review of the resident's POS dated for 9/29/24 to 10/29/24 showed:
-Order dated 4/7/24 assess dialysis site after dialysis for bruit and thrill, If not present call physician, monitor for active bleeding if present call physician once a day on Monday, Wednesday and Friday at 4:00 P.M.
-Order dated 8/1/24 Dialysis shunt assess for bruit and thrill every shift, if not present contact physician immediately, monitor for bleeding, if bleeding present contact physician every shift day and night shift.
-Lacked a physician's order for the dialysis provider's location, scheduled days, and time of treatment.
Review of resident's comprehensive care plan for renal disease and requires dialysis with a start date of 1/10/24 and edited 10/5/24 showed an intervention to obtain weights and labs from dialysis. Care plan failed to show the dialysis provider location, day, and time of treatment. The care plan lacked the location of shunt and not to provide treatments such as blood pressure or lab from his/her left arm and lacked documentation of the coordination of care between the facility and the dialysis provider.
Review of the resident's Dialysis Communication Binder on 10/29/24 at 10:56 A.M. showed:
-No documentation found for January 2024.
-No documentation found for 2/1/24; 2/3/24; 2/6/24; 2/8/24; 2/20/24; 2/13/24; 2/15/24.
-No documentation found for 3/3/24; 3/6/24; 3/8/24; 3/13/24; 3/17/24; 3/20/24; 3/22/24; 3/24/24; 3/27/24; 3/29/24 or 3/31/24.
-No documentation found for April 2024.
-No documentation found for 5/1/24; 5/3/24; 5/5/24; 5/12/24; 5/15/24; 5/19/24; 5/22/24; 5/26/24; or 5/31/24.
-No documentation found for 6/2/24; 6/5/24; 6/9/24; 6/14/24; 6/16/24; 6/19/24; 6/23/24; 6/28/24; 6/30/24.
-No documentation found for 7/5/24; 7/8/24; 7/12/24; 5/17/24; 7/26/24; 7/29/24; 7/31/24.
-No documentation in binder after 8/7/24.
Review of the resident's Dialysis Communication forms provided by the Director of Nursing (DON) on 10/30/24 at 8:43 A.M. showed:
-No documented vitals pre-dialysis and lacked information completed by the dialysis center on 9/11/24, 9/13/24, 9/18/24, 9/23/24, 9/27/24, 10/2/24, 10/7/24, 10/11/24, 10/16/24, and 10/21/24.
-Had pre-dialysis vitals but lacked information completed by the dialysis center on 9/16/24, 9/25/24, 9/30/24, 10/4/24, 10/8/24, 10/14/24, 10/18/24 and 10/28/24.
During an interview on 10/31/24 at 2:52 P.M., LPN A said:
-Nurses were to complete the pre-dialysis assessment and that form goes to the dialysis provider to complete their portion.
-Nurses assessed post dialysis per physician's order at 4:00 P.M.
-Vitals are not obtained unless the resident is not feeling well.
-Resident #75 was not always compliant in returning form.
-He/She would only call dialysis if there was a concern.
During an interview on 11/01/24 at 11:31 A.M., the Director of Nursing (DON) said:
-He/She expected a resident that returned from dialysis to be assessed.
-He/She expected the charge nurse to obtain the dialysis communication form.
-He/She expected the charge nurse to follow up with entering weights, address labs and file in chart, and enter any new orders for be addressed.
-He/She expected the charge nurse would follow up with the dialysis center if the communication form was not returned.
Based on observation, interview and record review, the facility failed to follow physician's orders for assessing the resident's dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly) shunt (a surgically created connection between an artery and a vein that allows for direct access to the bloodstream for dialysis) site twice daily, failed to ensure dialysis communication was received and documented after each dialysis treatment for continuum of care, and failed to include in the care plan the location and type of dialysis access and complete interventions on dialysis care needs for two sampled residents (Resident #68 and #75) out of 22 sampled residents. The facility census was 80 residents.
Review of the facility Hemodialysis policy and procedure dated 11/1/01, showed:
-Physician's orders for care of the hemodialysis resident should include information regarding visits to a dialysis center, along with care of the access site.
-Process for monitoring included palpate for a thrill and monitor the site for pain, swelling, redness or drainage, notify the physician if abnormalities are found.
-Obtain dry weights from the dialysis center.
-Obtain lab work from the dialysis center when performed.
-The policy did not show any procedure for continuum of care/routine communication with the dialysis center per treatment.
1. Review of Resident #68's Face Sheet showed the resident was admitted on [DATE], with diagnoses including kidney disease and renal failure (occurs when the kidneys are no longer able to filter waste and excess water from the blood, or maintain the body's chemical balance) with dialysis use.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/14/24, showed the resident:
-Was alert and oriented without confusion.
-Received a specialized treatment-dialysis.
Review of the resident's Physician's Order Sheet (POS) dated 10/2024, showed:
-The resident attended dialysis on Monday, Wednesday and Friday at 4:00 AM (10/11/24).
-Assess the resident's dialysis shunt for assess for bruit (a whooshing or rumbling sound caused by turbulent blood flow through a dialysis shunt) and thrill (vibration felt over a dialysis shunt, caused by blood flowing through it) every shift. If not contact physician immediately. Monitor for bleeding. If bleeding present, contact physician (7/3/24).
-Remove dressing from dialysis access site day after treatment once daily on Tuesday, Thursday and Saturday (8/28/24).
-Complete dialysis communication and send with resident on dialysis days (3/2/24).
Review of the resident's Care Plan dated 5/12/23 and updated on 10/25/24, showed the resident had kidney disease and required dialysis. Interventions showed:
-The resident at times refused dialysis.
-Apply pressure promptly if bleeding.
-Assess the resident's intake and output.
-Check the resident's bruit and thrill as ordered.
-Place a clean dry dressing over site (if bleeding) and hold pressure until emergency services arrives.
-Do not obtain blood pressure where the access site is located.
-Obtain weights and labs from dialysis.
-Provide and coordinate transportation to and from dialysis.
-The care plan did not show where the resident received dialysis or on what days he/she received it, what type of dialysis access the resident had and where it was located, how to care for the site and signs or symptoms of infection/adverse reactions to observe for and what to do if adverse reactions occurred.
Review of the resident's documentation of handwritten Dialysis Communication forms (for both the facility and dialysis vendor) from 12/2023 to 4/2024, showed:
-The facility's Dialysis Communication forms showed the facility's assessment of the resident's vital signs, frequency of dialysis, scheduled dialysis time, resident vital signs (pulse, respiration, blood pressure, temperature), medication sent with the resident, meal provision, transportation, time and facility contact number.
-The dialysis clinic documented (on their own vendor form) the resident's vital signs (blood pressure, pulse, temperature, weight), mentation, medications given and labs drawn on the form pre-dialysis treatment and post dialysis treatment. It also included any complications experienced at each visit.
-There were no handwritten dialysis communications forms documented after 4/2024.
Review of the resident's Dialysis Communication forms in the resident's electronic record showed the resident's name, date the communication was completed and recorded description and observation details. Observation details included the dialysis clinic, frequency of dialysis, scheduled dialysis time, resident vital signs, medication sent with the resident, meal provision, transportation, time and facility phone number. There was a section for the dialysis center to complete the resident's pre-weight, post weight, problems with the dialysis access site, whether the treatment was completed without incident, documentation of any lab work completed, medications given at dialysis, dietary recommendations and any recommendations/follow up. The documentation showed:
-The facility completed the dialysis communication form to include the resident's vital signs and medications sent with the resident and any further comments on 9/16/24, 9/24/24, 9/25/24, 9/30/24,10/8/24, 10/14/24, 10/18/24, and 10/28/24 (8 visits), out of 17 visits from 9/16/24 to 10/25/24.
-There was no documentation showing return communication from dialysis that showed the resident's pre-weight, post weight, problems with the dialysis access site, whether the treatment was completed without incident, documentation of any lab work completed, medications given at dialysis, dietary recommendations and any recommendations/follow up on any of the resident's communication forms out of 17 visits documented from 9/16/24 to 10/25/24.
Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 9/2024 and 10/2024, showed:
-Physician's orders to send the dialysis communication with the resident on dialysis days (Monday, Wednesday and Friday).
-Documentation showed the facility staff sent the dialysis communication form on 9/2/24, 9/4/24, 9/6/24, 9/9/24, 9/11/24, 9/13/24, 9/16/24, 9/18/24, 9/20/24, 9/23/24, 9/25/24, 9/27/24, 9/30/24, 10/2/24, 10/4/24, 10/7/24, 10/9/24, 10/11/24, 10/14/24, 10/16/24, 10/18/24, 10/21/24, 10/23/24, 10/25/24, and 10/28/24. There was no documentation return communication was obtained from dialysis on any of the dates.
-Physician's orders to assess the resident's dialysis access site for bruit/thrill every shift and monitor for bleeding. If not present or if bleeding present, contact physician immediately.
--Documentation showed during 9/2024, that nursing staff followed the physician's orders except on 9/9/24, 9/13/24, 9/19/24, 9/20/24, 9/23/24, 9/24/24 and 9/30 where on these dates documentation showed the nurse only checked the thrill and bruit on the night shift. On 15 occasions the nurse documented a zero, indicating there was no thrill or bruit, but there was no documentation showing the physician was notified of this on those dates.
--Documentation showed during 10/2024, that nursing staff followed physician's orders except on 10/2/24, 10/3/24, 10/7/24, 10/14/24, 10/17/24, 10/18/24, 10/21/24, and 10/27/24. On these dates, the nursing staff documented that the order was not followed due to the resident being unavailable. All of the dates showing the physician's orders were not followed occurred on the day shift except on 10/21/24 (night shift documented the resident was out of bed).
Observation and interview on 10/29/24 at 10:24 A.M., showed the resident was laying in bed with a blanket covering him/her. There was an area on his/her upper left inner arm that was covered with a bandage. There was no swelling or redness surrounding the area. The resident said this was his/her dialysis access site. He/She said:
-He/She had dialysis on Monday, Wednesday and Friday and his/her chair time was for 4:00 A.M.
-He/She was comfortable with his/her treatments and had not had any issues with his/her access site.
-On the days he/she went to dialysis, nursing staff took his/her vital signs, but at dialysis, they also took his/her vital signs and weights before and after his/her dialysis treatment.
-Upon returning from dialysis, the nurse did not normally check his/her shunt site, complete vital signs or weigh him/her, but the Certified Medication Technician (CMT) came in at night to take his/her blood pressure.
-He/She thought the dialysis center usually provided the facility with the documentation of his/her pre and post dialysis information, labs (when available) and communication after his/her dialysis treatments.
Observation and interview on 10/30/24 at 10:50 A.M., showed the resident had just returned from dialysis and was in his/her room laying on his/her bed without a shirt on. There was a white 4x4 dressing covering his/her dialysis access site. At 11:53 A.M., Licensed Practical Nurse (LPN) A knocked on the resident's door and entered the resident's room and said he/she was going to check the resident's dialysis site. He/she put on gloves and used his/her fingers to feel on and around the resident's dialysis access site. LPN A said he/she was feeling for a pulse or vibration in the area. He/She then took the stethoscope and put it on the site and said he/she was listening for the swishing sound to identify the site was patent. LPN A said:
-When the resident returned from dialysis the nurse was supposed to check the resident's access site to feel for the bruit and listen for the thrill.
-He/She did not hear the swishing sound nor did he/she feel the vibration at the resident's access site, but this was because the resident has low blood pressure which was not abnormal for him/her.
-If they are unable to hear or feel the thrill and bruit, they were supposed to notify the dialysis center and physician even though this is expected due to the resident's condition.
-With Resident #68, because the resident's blood pressure is normally low, they rarely are able to successfully feel and hear the resident's blood going through the access site when he/she comes back from dialysis, but the residents primary care physician and dialysis physician are both aware of the resident's low blood pressure and he/she received Midodrine that was administered several times daily to keep his/her blood pressure up and they take his/her blood pressures several times daily. He/She said in spite of this, they are still supposed to check the site and report any abnormality to the physician.
-He/She was supposed to document the findings in the resident's MAR on the day/time they make the observation.
-The resident was supposed to have his/her access site checked twice daily during the day and evening shift. She said the resident may not have his/her access site checked on the day shift due to the time he/she returned from the dialysis center, but it was checked at least once daily and they check it on the night shift. They document their monitoring on the resident's MAR.
-The nurses were supposed to complete the communication section of the resident's dialysis communication form prior to the resident going to dialysis and some of the residents will bring back communication forms from their dialysis that showed the vendor's documentation of the resident's pre and post weights, vital signs medications given and how much fluid was pulled off and if there were any complications during dialysis treatments.
-Resident #68 never brought back any documentation/communication from dialysis so he/she did not know any information about how the resident's dialysis treatment went or what his/her vital signs or weights were.
-If the nursing staff have any concerns regarding dialysis, they can/will call the dialysis center to request information.
-The resident's dialysis center will contact them if they have any concerns or need to notify them of any change in care, medications, or labs.
-They do not contact the resident's dialysis center after each dialysis visit to obtain information regarding the resident's dialysis treatments or information regarding his/her weights, medications given during dialysis, vital signs or fluids pulled at each treatment.
-He/She was going to notify the physician of the result he/she obtained when trying to check the resident's thrill and bruit today.
During an interview with the Corporate Nurse on 10/29/24 at 1:59 P.M., showed:
-The handwritten dialysis communication forms were in the dialysis book, but he/she was not sure all of the communications were in there for the resident and they may not all be there.
-The dialysis communication forms for the resident should be and were in the resident's electronic record.
-The return communication from dialysis should be in the resident's electronic record.
During an interview on 11/01/24 at 11:36 A.M., with the Director of Nursing (DON), the Regional Nurse Consultant, and the Regional Quality Assurance (QA) Nurse, the DON said:
-He/She would expect residents to be assessed upon return from dialysis and the thrill and bruit should be checked every shift.
-Documentation of the staff monitoring of the resident's thrill and bruit should be on the resident's MAR.
-They would not take the resident's vital signs unless there was an issue.
-He/She does expect the nurse to follow the physician's order for assessing the thrill and bruit.
-If the dialysis center does not return their assessment upon the resident's return, the nurse should call and ask the dialysis center if there is any information they need to know regarding the resident's treatment.
-Usually the dialysis center will reach out to the facility if there are issues during dialysis, but they do not normally receive documentation from dialysis showing their pre and post dialysis communication.
-They do expect the dialysis center to return documentation regarding their post assessment after treatment but they have had problems with the dialysis center being compliant with their requests for their communication.
-They have called to try to get information from the dialysis center about the resident's treatments but they do not call to request the resident's information after each dialysis treatment.
-When nursing staff have called to request information, he/she would expect nursing staff to document (when they have called to request information or when the dialysis center has refused to provide information) their communication in the resident's medical record.
-They were aware that the resident has low blood pressure and may not be able to get an accurate assessment of his thrill and bruit.
-With this resident, it is important to know what the resident's post dialysis assessment was after treatments.
-He/She would expect the nurse to notify the physician and document the notification and response in the resident's medical record.
-He/She would expect the resident's care plan to reflect that the resident has low blood pressures that may affect the ability to get the thrill and bruit.
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 and interview, the facility failed to have a regular system of checking food temperatures to ensure that hot foods (scrambled eggs) were maintained at or close to a temperature of...
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Based on observation and interview, the facility failed to have a regular system of checking food temperatures to ensure that hot foods (scrambled eggs) were maintained at or close to a temperature of 120°F (degrees Fahrenheit) on five trays for residents on the 500 Hall. This practice potentially affected five residents who were yet to receive breakfast room trays on 11/1/24. The facility census was 80 residents.
1. Observation on 11/1/24 showed:
-At 7:31 A.M., the cart with trays for the residents in the 500 Hall left the kitchen.
-From 7:34 A.M. through 7:38 A.M., trays were passed to residents who were in the 500 Hall dining room.
-From 7:40 A.M. through 7:45 A.M. trays were delivered to residents who wanted trays in their rooms.
-At 7:44 A.M., with Certified Nursing Assistant (CNA) A watching, the temperature of the eggs on one of the trays was measured at 113 °F .
During an interview on 11/1/24 at 7:46 A.M., CNA A said he/she had not seen anyone from the dietary department at the 500 Unit to check food temperatures.
During an interview on 11/1/24 at 7:49 A.M., Registered Nurse (RN) A said he/she had worked for two weeks on the unit and had not seen anyone from the dietary department check food temperatures.
During an interview on 11/1/24 at 8:21 A.M., Dietary [NAME] (DC) A said it had been about a month since he/she had checked food temperatures on the 500 Unit.
During an interview on 11/1/24 at 8:27 A.M., the Dietary Supervisor said he/she was not sure how long the trays sat before they were passed out.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to obtain a signature for the authorization of the opening of a resident trust account for one sampled resident (Resident #50) and failed to o...
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Based on interview and record review, the facility failed to obtain a signature for the authorization of the opening of a resident trust account for one sampled resident (Resident #50) and failed to obtain authorization signatures from sampled three residents (Residents #100, #41 and #62) to allow Supplemental Insurance Company A to withdraw funds from the accounts of those residents. This practice affected at least four residents who had resident trust accounts at the facility. The facility census was 80 residents.
Review of the facility's Business Office and Internal Controls Policy and Procedure Manual, dated 10/22 showed:
-Upon written authorization from the resident/guest or their agent, the facility must hold, safeguard, manage and account for the personal funds deposited with the facility.
-Funds may be expended from the facility's Resident Trust Petty Cash or by a Resident Trust Check Request.
-Anytime a transaction is made from the Resident Trust Fund, by request or by cash, it must be fully documented, supported by voucher or invoice, and approved by the resident, legal guardian, conservator or Power of Attorney (POA-- a legal document that allows someone to act on another person's behalf).
1. Review of Resident #50's authorization form (to open a resident trust account) showed the absence of the resident's signature or a signature from the resident's POA. The resident trust account was opened on 4/5/23.
Review of written communication from the facility to the resident's POA dated 4/3/23 showed the POA returned the form back to the facility on 4/4/23 unsigned.
During an interview on 10/29/24 at 10:58 A.M., the Financial Specialist said he/she did not believe any other outreach has been done to the resident's POA, since April of 2023.
2. Review of Resident #100's Resident Trust account records, showed:
-A check for $636.00 dated 8/6/24, was written to Supplemental Insurance Company A for dental insurance premium.
-A check for $159.00 dated 8/6/24, was written to Supplemental Insurance Company A for vision insurance.
-No signatures by Resident #100 to allow Supplemental Insurance Company A to be able to obtain that money.
During an interview on 10/29/24 at 9:52 A.M., the Financial Specialist said:
-Resident #100 had a withdrawal of $636.00 on 8/6/24 for insurance premiums which were $159.00 each month for four months (4/24 through 8/24).
-Another check was written for $159.00 on 9/3/24.
-Another check was written for $159.00 on 10/1/24
-There were not any signatures by the resident in 4/24, at the beginning of the residents purchasing of services from Supplemental Insurance Company A and no signatures to authorize any transactions in 8/24.
3. Review of Resident #41's Resident Trust Account records showed:
-On 8/2/24, a check for $236.00 dated 8/2/24, was written to Supplemental Insurance Company A for vision insurance,
-On 8/2/24, a check for $636.00 dated 8/2/24, was written to Supplemental Insurance Company A for dental Insurance,
- Review of Resident #41's Resident Trust records with the Financial Specialist, showed the absence of signature from Resident #41 on any of the forms which were dated August 2024
4. Review of Resident #62's Resident Trust Account records showed:
-On 8/2/24, a check for $708.00 dated 8/2/24 was written to Supplemental Insurance Company A for vision insurance
-On 8/2/24, a check for $636.00 dated 8/2/24 was written to Supplemental Insurance Company A for dental Insurance
-The absence of a signature by Resident #62 to authorize Supplemental Insurance Company A to have those checks written.
During an interview on 11/1/24 at 10:08 A.M. the Financial Specialist said:
-After he/she reviewed the resident trust records of Residents #100, #41 and #62, he/she did not see there were signatures from any of those residents to authorize payments to Supplemental Insurance Company A.
-Supplemental Insurance Company A signs up the residents but the company did not provide facility personnel with copies of the signed paperwork with the resident's signature.
-The facility is supposed to obtain signatures from the residents when they first sign up with Supplemental Insurance Company A.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) and/or the Notice of Medicare Provider Non-Cover...
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Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) and/or the Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) for three sampled residents (Resident #78, #139 and #102) out of three sampled residents who were discharged from Medicare part A services. The facility census was 80 residents.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following:
-The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) was issued when all covered Medicare services end for coverage reasons.
-If the skilled nursing facility (SNF) believed on admission or during a resident's stay that Medicare would not pay for skilled nursing or specialized rehabilitative services and the provider believed that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters.
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have.
-If the SNF provided the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider had met the obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination.
1. Review of Resident #78's SNF Beneficiary Protection Notification Review form completed by Financial Specialist showed:
-The resident discharged from Medicare Part A services on 6/23/24 and stayed at the facility.
-The NOMNC had not been provided to the resident or the resident's responsible party because he/he had been using the incorrect form.
2. Record review Resident #138's SNF Beneficiary Protection Notification Review form completed by Financial Specialist showed:
-The resident discharged from Medicare Part A services on 6/30/24 and stayed at the facility.
-The NOMNC had not been provided to the resident or the resident's responsible party because he/he had been using the incorrect form.
3. Review of Resident #102's SNF Beneficiary Notification Review form completed by Financial Specialist showed:
-The resident discharged from Medicare Part A services on 7/26/24 and went home.
-The NOMNC had not been provided to the resident because the resident requested to go home.
Review of the resident's electronic medical record showed no documentation the resident requested to self-discharge off Medicare Part A services.
During an interview on 10/31/24 at 1:40 P.M. the Financial Specialist said:
-He/She was responsible for providing the NOMNCs and SNF ABNs to the residents.
-The residents were given a 48-hour notice prior to the Medicare Part A discharge date .
-He/She would call the resident's responsible party and notify them over the phone 48 hours prior to the Medicare Part A discharge date .
-In certain situations, the NOMNC and ABN will be given in advance.
-He/She had been giving out the wrong NOMNC.
-He/She thought the Medicare Part B form was the NOMNC form.
-He/She had been trained to use the Medicare Part B form as the NOMNC form upon hire.
-He/She gave the ABN form to the resident and/or resident responsible party.
-He/She gives the form to every resident who is discharged or stay in the facility.
-Resident #102 requested to discharge to home so the no forms were provided to the resident.
-He/She could not locate any information in the resident electronic medical record showing the resident decided to discharge home.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the following resident rooms clean and free from a buildup o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the following resident rooms clean and free from a buildup of dust and food debris on the floors and walls: resident rooms 508, 207, 202, 201, 200, 301, 303, 302, 300, 403, 404, 401, 105, and 107. This practice potentially affected 24 residents who resided in those rooms. The facility census was 80 residents.
1. Observations with the Maintenance Director on 10/30/24, showed:
-At 1:36 P.M., there was a heavy buildup of cobwebs (a web spun by certain spiders, often found in the corners of disused rooms) between the climate control unit and the night stand in resident room [ROOM NUMBER].
-At 2:37 P.M., there was a heavy buildup of cobwebs which stretched between the floor and the climate control unit.
-At 2:40 P.M., there was a heavy buildup of food crumbs in he corner between the bed and the window in resident room [ROOM NUMBER].
-At 2:43 P.M., there was a buildup of dust on the fans in resident room [ROOM NUMBER].
-At 2:44 P.M., there was a buildup of debris including grass clippings and grime on the floor next to the climate control unit in resident room [ROOM NUMBER].
Observations with the Maintenance Director on 10/31/24, showed:
-At 9:46 A.M., there was a buildup of debris such papers under the bed in resident room [ROOM NUMBER].
-At 9:48 A.M., there was the presence of debris under the beds in resident room [ROOM NUMBER].
-At 10:05 A.M., there was debris under the bed in resident room [ROOM NUMBER].
-At 10:14 A.M., a trash container with soiled items (adult briefs etc.) was stored in the 300 Hall shower room, which caused a pungent urine odor in that shower room.
-At 10:31 A.M., there was an old plastic pink bedpan under the bed in resident room [ROOM NUMBER].
-At 10:34 A.M., there was a buildup of dust under the beds in resident room [ROOM NUMBER].
-At 10:47 A.M., there was a buildup of food crumbs and debris in the corner next to the bed closest to the door in resident room [ROOM NUMBER].
-At 11:21 A.M, there was a buildup of candy pieces behind the bed in resident room [ROOM NUMBER]. and
-At 11:27 A.M., there was dust and debris under the bed in resident room [ROOM NUMBER].
During an interview on 11/01/24 at 9:06 A.M., the Housekeeping Supervisor said:
-He/She has been the housekeeping supervisor since 6/24.
-After seeing the buildup of cobwebs in resident room [ROOM NUMBER] , he/she said that the housekeepers go into rooms where the residents do not want the housekeeper to move their items so it was harder for the housekeepers to get into areas to clean properly.
-The trash container should not be in the shower room, instead the trash container should be in the soiled utility room.
-He/She noticed the buildup of cobwebs, the dead insects and dust behind the night stand in resident room [ROOM NUMBER].
-He/She noticed the buildup of plastic bags and debris behind nightstand in resident room [ROOM NUMBER].
-He/She noticed the pieces of candy and the buildup of dust on the floor in resident room [ROOM NUMBER].
-He/She noticed the dust buildup on the fan in resident room [ROOM NUMBER] and the housekeepers should clean the fan once per week.
-He/She expected the housekeepers to do as much they can without hurting themselves and his/her department was short of a housekeeper for a period of time earlier in 2024.
During an interview on 11/01/24 at At 9:15 A.M., Nursing Assistant (NA) A said the trash container should be in the soiled utility room.
During an interview on 11/1/24 at 2:17 P.M., the Administrator said he/she did not know why that pink bedpan was under the bed in resident 403 and he/she did not know how long that pink bedpan had been there.
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** 7. Review of the facility Smoking policy and procedure, dated 10/29/17 showed:
-The facility must comply with federal, state, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of the facility Smoking policy and procedure, dated 10/29/17 showed:
-The facility must comply with federal, state, and local regulations regarding smoking in healthcare facilities.
-There was no documentation showing how often staff were to complete smoking assessments for residents to ensure they could smoke safely.
Review of Resident #61's Face Sheet showed the resident was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation) and tobacco use.
Review of the resident's admission Progress Note dated 9/19/24 showed the resident was a current every day smoker.
Review of the resident's admission MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Used tobacco products.
Review of the resident's Care Plan dated 10/2/24, showed:
-The resident smoked cigarettes.
-The staff were to instruct the resident about smoking schedule and rules.
-The resident was to be observed while smoking by staff.
Review of the resident's electronic medical record on 10/29/24 showed:
-No documentation the facility staff had completed an initial smoking assessment.
-There was no documentation showing the resident was able to safely smoke and abide by the facility smoking policy.
During an interview on 10/28/24 at 11:42 A.M., the resident said he/she goes outside and smokes cigarettes five times a day.
During an interview on 10/31/24 at 2:21 P.M., LPN C said:
-Upon admission, he/she would ask the resident if he/she smoked cigarettes.
-If the resident said yes, he/she would notify the Social Services Director (SSD) to complete a smoking assessment on the resident.
-The SSD was responsible for completing all smoking assessment on the residents.
-The smoking assessments were completed upon admission, quarterly or if there was a change in the resident's condition.
-Resident #61 should have had a smoking assessment completed.
-All residents that smoke cigarettes have a contract that was signed by the resident stating that he/she agreed to follow the facilities rules about smoking.
During an interview on 11/1/24 at 9:16 A.M., the SSD said:
-If a resident smoked cigarettes, he/she signed a contract agreeing to the rules.
-Nurses were responsible for completing residents smoking assessments.
-A resident would be assessed by the nurse to see if he/she could hold and light a cigarette safely.
-The smoking assessments were done upon admission and every quarter.
-The Director of Nursing or any nurse were responsible for the completion of the smoking assessment.
-Resident #61 should have had a smoking assessment completed.
During an interview on 11/1/24 at 11:36 A.M., the DON, RNC, and RQAN, the DON said:
-A smoking assessment was needed to make sure the resident was able to smoke cigarettes without any concerns or if he/she would need some kind of protection like a smoking apron.
-He/She would use the assessment to determine if the resident can smoke cigarettes safely.
-The smoking assessments were completed upon admission and annually.
-The nurses or nursing management were responsible for completing the smoking assessments.
-The smoking assessments were completed by the interdisciplinary Team (IDT).
-All assessments are kept electronically in the resident's medical record.
-The RNC said:
-If the resident was a smoker at the time of admission, he/she should have had a smoking assessment completed.
-He/She would observe the resident to determine if he/she could smoke safely.
6. A policy for gait belt use was requested but not received from the facility at the time of exit.
Review of Resident #19's Face Sheet showed the resident was admitted on [DATE], with diagnoses including Parkinson's Disease (a movement disorder of the nervous system that worsens over time) and blindness.
Review of the resident's MDS dated [DATE], showed:
-The resident was alert and oriented with minimal confusion.
-Had had no functional impairment in range of motion and used a walker for mobility.
-Was dependent for toileting and required moderate assistance for upper and lower body dressing.
-Needed supervision to touching assistance to go from a siting to lying position, lying to sitting, sitting to standing, transfer to/from bed to chair, and transfer to/from the toilet.
-Had no falls during the look back period.
Review of the resident's Nursing Notes showed the resident had a recent unwitnessed non-injury fall on 10/28/24 and the resident sustained a skin abrasion to his/her right elbow.
Review of the resident's Care Plan dated 4/12/27 and revised on 10/28/24, showed the resident required staff assistance with all cares due to visual disturbances and tremors, It also showed the resident had the potential for falls related to poor safety awareness and blindness.
Observation and interview on 10/30/24 at 1:15 P.M., showed the resident was laying down on his/her bed in his/her room. Certified Nursing Assistant (CNA) B entered the resident's room and assisted the resident to sit up on the side of his/her bed. CNA B then pulled the resident's walker up to him/her and the resident was able to hold onto the walker as CNA B assisted the resident to stand without using a gait belt. Once the resident was standing, he/she said he/she needed to go to the bathroom and CNA B provided standby assist and direct assistance of the resident as he/she walked with his/her walker to the bathroom, as the resident became unsteady while walking. LPN B, who was watching CNA B assisting the resident to walk, went to get a gait belt and gave it to CNA B to put on the resident. The resident was in the bathroom at this time.
During an interview on 10/30/24 at 1:24 P.M., LPN B said:
-The resident normally was able to ambulate without any assistance with his/her walker, but he/she was having more shaking related to his/her Parkinson's disease today and needed the assistance to walk.
-He/She went to get the gait belt when he/she did not see the resident wearing one while CNA B was assisting him/her.
-CNA B should have placed a gait belt on the resident because he/she was physically assisting him/her with walking to the bathroom.
During an interview on 10/30/24 at 1:58 P.M., CNA B said:
-He/She went to the resident's room to feed him/her because the resident was shaking more and did not want to go to the dining room.
-He/She assisted the resident to transfer to his/her walker and to the bathroom because he/she was unsteady on his/her feet.
-He/She did not have a gait belt available at the time and there was no gait belt in the room so he/she did not use one.
-He/She knew he/she should have used a gait belt when assisting the resident to stand and walk.
During an interview on 11/1/24 at 11:36 A.M., with the Director of Nursing (DON), Regional Nurse Consultant (RNC), and Regional Quality Assurance Nurse (RQAN), the DON said:
-If the resident is ambulating independently, they would not need to wear a gait belt if they were only providing stand by assistance only.
-If the nursing staff provide any hands on assistance with ambulation, they are to use a gait belt.
-The nursing staff do not carry gait belts with them.
-Each resident has a gait belt in their room that is designated for use with that resident and the gait belts are hanging in each resident closet.
-He/She was made aware that the nursing aide had not worn a gait belt when assisting the resident and the nursing staff should have worn one.
Based on observation, interview, and record review, the facility failed to maintain the hot water temperature at or below 120 °F (degrees Fahrenheit) in the room of Residents #2 and #76 and in the room of Residents #26 and #77; failed to use a gait belt when assisting one sampled resident to ambulate (Resident #19) who was unsteady on his/her feet; and failed to ensure an initial smoking assessment was completed to establish a baseline for the ability of one resident to smoke, determine assistance as necessary, and ensure safe smoking habits were in place for one sampled resident (Residents #61) out of 22 sampled residents. The facility census was 80 residents.
1. Review of the temperature log dated 10/14/24, showed the following hot water temperatures:
-In the 100 Hall the temperature was 102 °F.
-In the 200 Hall, the temperature was 102°F.
-In the 300 Hall, the temperature was 104°F.
-In the 400 Hall, the temperature was 105°F
-In the 500 Hall, the temperature was 104°F.
-The particular rooms on each hall were not identified.
During an interview on 11/1/24 at 12:54 P.M., the Maintenance Director said he/she had not identified the particular rooms on each hall in hot water temperatures were checked.
2. Observation on 10/31/24 at 10:02 A.M., with the Maintenance Director, showed the temperature of the hot water heater for that hall, was set at 165 °F and that hot water heater also served the laundry which was on that hall.
During an interview on 10/31/24 at 10:03 A.M., the Maintenance Director said the hot water heater did not need to be set at that high of a temperature.
3. Review of Resident #2's quarterly Minimum Data Set (MDS--a federally mandated assessment tool completed by the facility for care planning) dated 8/20/24, identified the resident as:
-A resident who needed minimal assistance for transfers and ambulation.
-A resident who had moderate cognitive impairment.
Review of Resident #76's quarterly MDS dated [DATE], identified the resident as
-A resident who required substantial assistance for transfers and ambulation.
-A resident who was severely impaired in cognitive skills for daily decision-making.
Observation on 10/31/24 at 9:54 A.M. with the Maintenance Director, showed the temperature of the hot water in the room of Residents #2 and #76 was between 126-128.2 °F, after the water from the faucet was allowed to flow for two or more minutes.
Observation on 10/31/24 at 1:54 P.M., with Certified Medication Technician (CMT) A showed the temperature of the hot water in the Resident #76's and #2's room, was 129.7 °F.
During an interview on 10/31/24 at 1:55 P.M., CMT A said he/she did not know the water in that room was so hot after he/she washed his/her hands.
Observations on 11/1/24 at 9:35 A.M., showed the hot water temperature in Resident #76's and #2's room was 128.4°F.
4. Review of Resident #26's quarterly MDS dated [DATE] identified the resident as:
-A resident who was required no assistance from a helper in transfers. and ambulation.
-A resident who had severe cognitive impairment.
Review of Resident #77's quarterly MDS dated [DATE], identified the resident as
-A resident who needed minimal assistance for transfers and had not performed any ambulation in the 7 days prior to the date of the MDS.
-Resident who had severe cognitive impairment.
Observation on 10/31/24 at 9:56 A.M. with the Maintenance Director, showed the temperature of the hot water in the room of Residents #26 and #77, was between 126.5°F, after the water from the faucet was allowed to flow for two or more minutes.
Observation on 10/31/24 at 1:58 P.M., showed the temperature of the hot water in the Resident #26's and #77's room, was 129.5 °F.
Observations on 11/1/24 at 9:32 A.M., showed the hot water temperature in Resident #26's and #77's room was 130.0°F.
5. During an interview on 10/31/24 at 2:03 P.M., CMT A said:
- Neither Resident #76 nor Resident #2 were able to get to the handwashing faucet on their own because both residents needed assistance in ambulating.
- Resident #26 was able to ambulate without assistance but did not have enough cognitive ability to be able to mix the hot and cold water.
- Resident #77 was able to ambulate to the handwashing faucet and had the cognitive ability to mix the hot and cold water at the faucet.
** At the times of the observations no residents attempted to go towards the handwashing faucet.
During an interview on 10/31/24 at 2:07 P.M., Licensed Practical Nurse (LPN) A said:
- Residents #76 and #2 were not able to get to the handwashing faucet on their own, because they needed assistance in transfers.
- Resident #26 was capable of getting to the handwashing faucet on his/her own, but only had the cognitive ability to mix the hot and the cold on some days and on other days. He/she was not able to mix the hot and cold water.
- Resident #77 had the cognitive ability to mix the hot and cold water on his/her own.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the resident undated Face Sheet showed his/her most recent admission was 12/14/2023 with a diagnosis of COPD.
Revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the resident undated Face Sheet showed his/her most recent admission was 12/14/2023 with a diagnosis of COPD.
Review of resident's quarterly MDS dated [DATE] showed:
-The resident had some cognitive impairment that needed support from staff.
-He/She was receiving oxygen.
Review of resident's POS for 10/1/24 to 10/29/24 showed an order for oxygen at 2 to 4 liters per minute per nasal cannula as needed for shortness of breath.
Review of resident's care plan showed a problem of oxygen therapy with interventions to include:
-Administer oxygen therapy as ordered.
-Change tubing per protocol.
Observation on 10/28/24 at 8:28 A.M. showed the oxygen tubing for the E-tank (a portable oxygen tank) was draped over the wheelchair and not bagged.
Observation on 10/29/24 at 12:59 P.M. showed the oxygen tubing for his/her concentrator in the room drapped over the bedside table and was not bagged.
Observation 10/30/24 at 9:09 showed the resident up in wheelchair with oxygen tubing to his concentrator on. The external filter to the concentrator was missing, and the concentrator had a buildup of dust and grime. Oxygen tubing for the E-tank was draped over wheelchair and not bagged.
5. During an interview on 10/29/24 at 10:16 A.M., CNA A said:
-The CPAP face mask and oxygen tubing should be in a bag when it is not in use and they (staff) should label and date the bag.
During an interview on 11/01/24 at 11:36 A.M., with the DON, Regional Nurse Consultant, and the Regional Corporate Quality Assurance (QA) Nurse, the DON said:
-Oxygen tubing, face masks and CPAP/BiPAP supplies should be stored in dated bags when not in use to prevent contamination.
-An order should be in the resident's record for oxygen therapy, CPAP use and changing the oxygen tubing and storage bags.
-The night shift nurses were responsible for changing out the tubing weekly at night.
-CPAP masks should be bagged when not in use and there should also be an order showing when the mask and bags are to be changed.
-He/She expected the filters and concentrators were cleaned weekly on Wednesdays by night shift.
2. Review of Resident #81's quarterly MDS assessment, dated 10/16/24, showed:
-Diagnoses of COPD and chronic respiratory failure.
-The resident received oxygen therapy but did not use a CPAP device.
Review of the resident's POS, dated 11/1/24, showed no orders for oxygen administration or the use of a CPAP machine.
Review of the resident's Care Plan, dated 10/21/24, showed:
-The resident received oxygen therapy.
-Staff were to change tubing per protocol.
-No specifications to the rate or frequency of oxygen to be administered.
Observation on 10/28/24 at 9:13 A.M., showed:
-The resident in his/her room with oxygen being administered through a nasal cannula at 2 liters per minute.
-A CPAP device near the resident's bed, with tubing that ran across the ground and a mask that rested uncovered on a tote near the resident's bed.
-No dates on the oxygen tubing or CPAP mask/tubing.
-No bags or areas to place the mask or tubing when not in use.
Based on observation, interview and record review, the facility failed to ensure physician's orders for a Continuous Positive Airway Pressure (CPAP a form of positive airway pressure ventilation in which a constant level of pressure greater than atmospheric pressure is continuously pumped into the lungs during spontaneous breathing) machine was on their Physician's Order Sheet (POS), care plan for one sampled resident (Resident #37); and failed to ensure respiratory face masks and tubing were kept covered when not in use for three sampled residents (Resident #68, #81, and #59) out of 22 sampled residents. The facility census was 80 residents.
Review of the facility's Policy Continuous Positive Airway Pressure revised 6/15/16 showed:
-CPAP should be administered under order of the attending physician.
-Obtain physician order for the rate of flow/pressure setting for CPAP and frequency of use.
-Mask/nasal pillows and flexible tubing should be washed, per manufacturers guidelines with mild soap and water, rinse thoroughly and air dry.
Review of the facility's Policy Oxygen Administration dated 12/8/05 showed:
-Oxygen (O2) cannula/mask should be stored in plastic bag when not in use.
-Obtain physician order for the rate of flow and route of administration of oxygen (i.e. by tank, concentrator, nasal cannula, mask, etc.).
1. Review of Resident #37's admission Face sheet showed the resident had a diagnosis of:
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/19/24 showed he/she:
-Was cognitively intact, able to make his/her needs and wants known.
-Had no documentation that the resident required the use of a CPAP machine.
Review of the resident's Care Plan dated 9/17/24 showed the resident:
-Was receiving Oxygen Therapy.
-Intervention include administer oxygen therapy as needed and ensure that supplies were always available.
-NOTE: Did not have a care plan for the use and the care of CPAP machine and mask.
Review of the resident's POS dated 10/1/24 to 10/31/24 showed he/she had the following orders:
-Did not have a detailed physician's order for use and monitoring/care of the residents CPAP machine and supplies.
-No documentation of the resident's use of the CPAP machine at bedtime or as needed.
Review of the resident's Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 10/1/24 to 10/31/24 showed:
-Did not have a detailed physician's order for use and monitoring/care of the residents CPAP machine and supplies.
-No documentation of the monitoring of the resident's use of the CPAP machine at bedtime or as needed.
Observation on 10/28/24 at 8:20 A.M., showed the resident had a CPAP machine next to the bed on the dresser with a face mask laid on the resident bed uncovered.
Observation on 10/29/24 at 12:33 P.M. showed:
-A CPAP machine sitting on the dresser.
Observation on 10/30/24 at 12:56 P.M., showed the resident had a CPAP machine sitting on the dresser, mask laid on bed uncovered.
During an interview on 10/30/24 at 2:23 P.M. the resident said:
-He/She wore the CPAP at night.
During an interview on 11/1/24 at 8:16 A.M., Certified Medication Technician (CMT) A said:
-The resident use CPAP at night.
During an interview on 11/1/24 at 8:40 A.M., Certified Nursing Assistant (CNA) E said:
-CPAP should have a physician order, he/she would refer to the nursing staff about the physician order and care for a CPAP machine.
During an interview on 11/01/24 at 8:56 A.M., Registered Nurse (RN) B said:
-He/she would expect to have physician's order for use of CPAP.
Review of the resident's electronic record on 11/1/24 at 9:02 A.M., with RN B showed:
-He/she did not find a physician order for Resident #37 use of CPAP machine and care of mask or supplies.
-RCN said he/she did not find a physician order for CPAP.
-RCN said he/she would expect to have detail physician order for use of CPAP machine and care for mask. Care plan updated with use and monitoring of the CPAP machine and supplies.
During an interview 11/01/24 at 11:36 A.M., the Director of Nursing (DON) said:
-Would expect to have a physician order for Resident#37 use of CPAP machine to include the settings, supplies needed for CPAP machine and the cleaning of face mask.
-Would expect to have care plan to include resident use of a CPAP.
3. Review of Resident #68's Face Sheet showed the resident was admitted on [DATE], with a diagnosis of sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become shallow during sleep).
Review of the resident's quarterly MDS dated [DATE], showed the resident:
-Was alert and oriented without confusion.
-Had a specialized treatment- a non-invasive ventilator (CPAP/bilevel positive airway pressure (BiPAP, a noninvasive breathing machine that helps people breathe when they have medical conditions that make it difficult).
Review of the resident's POS dated 10/2024, showed physician's orders for:
- CPAP/BiPAP setting and ensure distilled water is full in the reservoir at bedtime daily at 9:00 P.M.
Review of the resident's Care Plan updated on 10/25/24, showed the resident had sleep apnea and used a CPAP/BiPAP at bedside. Interventions showed staff would:
-Administer oxygen therapy as ordered.
-Change the tubing per protocol.
Observation on 10/28/24 at 8:39 A.M., showed the resident was not in his/her room. There was a CPAP/BiPAP machine sitting on the nightstand beside the resident's bed. The resident's face mask and tubing was left uncovered and laying on top of the resident's bed. There was a brown substance on the linen on the bed that was next to the face mask.
Observation on 10/29/24 at 9:54 A.M., showed the resident was laying on his/her bed and nursing staff was preparing to provide care to him/her/ On the nightstand beside the resident's bed was his/her CPAP/BiPAP machine and the face mask and tubing was laying on top of it, uncovered.
Observation and interview on 10/29/24 at 10:24 A.M., showed the resident's CPAP/BiPAP machine was still on his/her nightstand and the face mask and tubing was still laying on the machine, uncovered. The resident said he/she used the CPAP/BiPAP when he/she was sleeping at night and when he/she awoke, he/she placed the face mask on the machine. He/She said he/she did not usually have a bag for the face mask.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to maintain documentation and ensure that Certified Nursing Assistants (CNAs), and licensed nursing staff had the appropriate competencies an...
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Based on interview, and record review, the facility failed to maintain documentation and ensure that Certified Nursing Assistants (CNAs), and licensed nursing staff had the appropriate competencies and skills check off completed annually and as needed. This had the potential to effect any resident care provided by care staff. The facility census was 80 residents.
Review of the Facility Assessment dated 8/8/24 showed:
-The facility has staff skills and competencies to address the current and future needs of the facility's resident.
-The facility had reviewed staff training and inservices program and determined that it is appropriate to provide the level and types of care needed for the resident population outlined in this assessment. The facility also reviewed staff competencies and skills sets and determined that competencies and skills sets for both staff and contractors were appropriate.
1. During the entrance conference on 10/28/24 at 9:07 A.M., the Administrator said:
-The facility does not currently have an Assistant Director of Nursing (ADON).
-The facility had residents with tracheostomy (surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions), wounds, colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen), Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine), tube feeding (a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing), and dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood).
Review of employees annual inservices and training records from 10/1/23 to 10/31/24 showed the facility did not have documentation of the staff completed skill and competency check off records.
On 10/31/24 at 1:56 P.M. request the facilities staff competency skills check off for sampled employees.
During an interview on 11/1/24 at 8:16 A.M., Certified Medication Technician (CMT) A said:
-He/She had completed a competency skills check off about 4-5 months ago.
-He/She did not keep a copy for his/her record.
During an interview 11/1/24 at 11:11 A.M., Director of Nursing (DON) and Licensed Practical Nurse (LPN) B said:
-The facility did not have staffing coordinator at that time.
-The staffing coordinator would have been responsible for coordination of competency and skills check off, and maintaining staff competence and skill check off documentation.
-The DON and LPN B were assisting with staff scheduling and training as needed until new staff were hired.
-Staffing coordinator would normally coordinate a skills lab to be completed annually and as needed.
-DON said: he/she was not able to locate the staff competency and skills documentation at that time for all nursing, CMT, CNA competency and skill completed.
-DON would expect the facility staff coordinator to ensure to maintain and secure staff competency and skills check off documentation that had been completed for that year.
On 11/1/24 at 2:06 P.M., at the time of exit, the facility administration were not able to find documentation of facility staff competency and skill check off that had been completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the covers of cleanouts (an access point which provides acce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the covers of cleanouts (an access point which provides access to the sewer or other plumbing line so that blockages can be removed) in a tight-fitting manner so the covers would not be a hazard to facility residents or staff located on the 100 Hall and on the 400 Hall. This practice potentially affected 31 residents who resided on those halls.
1. Observations on 10/29/24 at 1:23 P.M. and on 10/31/24 at 10:29 A.M., showed the cleanout cover outside of resident room [ROOM NUMBER] was loose when it was stepped on.
During an interview on 10/31/24 at 10:30 A.M., the Maintenance Director said there has not been any work completed around that cleanout since he/she started his/her tenure at the facility in April 2024.
2. Observations on 10/31/24 at 11:31 A.M., showed the cleanout cover between 107 and 108 was loose when it was stepped on.
During a phone interview on 11/6/24 at 3:08 P.M., the Maintenance Director said he/she expected the housekeeping staff who cleaned the floors in the hallways to notify him/her if one of those cleanout covers was loose.
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 and interview, the facility failed to maintain the floors in the dry goods storage room; maintain under and behind the ice machine free from food debris and grime; failed to maint...
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Based on observation and interview, the facility failed to maintain the floors in the dry goods storage room; maintain under and behind the ice machine free from food debris and grime; failed to maintain the ceiling vents and the fan free from a dust buildup; failed to maintain the milk that was served to residents in the 500 Hall at or close to 41°F (degrees Fahrenheit); and failed to maintain the toaster free from a buildup of crumbs at the bottom of the toaster. This practice potentially affected 77 residents who ate food from the kitchen. The facility census was 80 residents.
1. Observations on 11/1/24 from 6:04 A.M. through 8:29 A.M., showed:
-The presence of food crumbs, including an old orange behind the canned goods storage
-The presence of food crumbs in the corner close to the chest freezer in the dry goods storage room.
-A buildup of dust on the ceiling vent over the food preparation table.
-A buildup of grime and food debris behind the ice making machine.
-A heavy buildup of bread crumbs at the bottom of the two-slice toaster.
-The presence of dust on the fan in the kitchen.
During an interview on 11/1/24 at 7:29 A.M., the Dietary Supervisor said:
-The dietary staff should clean the dry goods store room on a regular basis.
-He/She was surprised to see the shelves were not moved.
-The shelves with the canned goods should have been moved so that dietary staff could get behind that area more thoroughly.
During an interview on 11/1/24 at 7:33 A.M., the Dietary Supervisor said the housekeeping department was supposed to clean the floors in the area where the ice machine was located.
During an interview on 11/1/24 at 8:27 A.M., the Dietary Supervisor said:
-He/She has not developed a cleaning schedule for the toaster.
-They have a cleaning list for the dietary staff, but he/she needed to outline the duties with all dietary staff.
During an interview on 11/1/24 at 9:32 A.M., the Housekeeping Supervisor said it was the responsibility of both departments (dietary and housekeeping) to clean the floor, but it was very difficult to get behind the ice machine to clean the floor properly.
During an interview on 11/1/24 at 11:35 A.M., the Administrator said he/she has seen housekeeping staff scrub the floors where the ice machine was located, but he/she should discuss a plan for cleaning that floor with the Housekeeping Supervisor and the Dietary Supervisor.
2. Observation on 11/1/24 at 7:42 A.M., showed the whole milk had a temperature of 50.1°F, when the temperature was measured after the Social Service Director poured the milk in a glass for measuring.
During an interview on 11/1/24 at 7:46 A.M., the Activities' Director said he/she had not seen anyone form the dietary department at the 500 Unit to check temperatures of the foods.
During an interview on 11/1/24 at 8:27 A.M., the Dietary Supervisor said:
-No one was going to the 500 Unit to check the temperatures of the milk.
-The milk was not maintaining the temperature that it is supposed for the entire time because the ice bath that the milk container sits in, melts.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #59's quarterly MDS dated [DATE] showed:
-The resident had some cognitive impairment that needed support f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #59's quarterly MDS dated [DATE] showed:
-The resident had some cognitive impairment that needed support from staff.
-He/She had an indwelling catheter.
-He/She required moderate assistance for toileting hygiene, shower/bathing, upper body dressing, lower body dressing and the putting on and taking off of footwear.
Review of the resident's October 2024 POS showed enhanced barrier precautions during direct care related to foley catheter dated 12/14/23.
Review of the resident's care plan start date 12/29/23 showed the problem of Foley catheter with an intervention to perform enhanced barrier precautions for foley catheter care.
Observation on 10/28/24 at 8:28 A.M. a sign on the resident's door for Enhanced Barrier Precautions showed:
-Everyone must clean their hands, including before entering and when leaving the room.
-Providers and staff must also wear gloves and a gown for the following high-contact resident care activities:
--Providing hygiene.
--Changing briefs or assisting with toileting.
--Device care or use with central line urinary catheter, feeding tube, and tracheostomy.
During an interview on 10/31/24 at 2:41 P.M., Licensed Practical Nurse (LPN) A said the process for foley catheter care included:
-Wash hands, don gloves, complete catheter care, then perform hand hygiene prior to leaving the room.
-He/She was not aware of EBP and was not aware staff were required to wear a gown while completing cares for residents on EBP.
-He/She thought the sign was related to what to do if a resident had COVID (a new disease caused by a novel (new) coronavirus).
-He/She did not wear a gown when completing the resident's catheter cares.
During an interview on 11/01/24 at 11:31 A.M., the DON said:
-He/She expected staff to perform Enhanced Barrier Precautions.
-EBP would involve gown and glove use during high-contact resident care.
-He/She was not aware staff had not used EBP for Resident #59 during catheter care.
10. Review of a policy titled General Dose Preparation and Medication Administration, dated 12/1/07, showed:
-Staff were to perform hand hygiene prior to beginning a medication administration/preparation.
-Staff were not to touch medications during preparation or administration.
-Medications that were dropped should be discarded.
During an observation on 10/30/24 at 11:11 A.M., Certified Medication Technician (CMT) B administered a medication by mouth to Resident #101 in his/her room. After administration, CMT B returned to the medication cart, prepared two tablets of Acetaminophen (a pain reliever) 325 milligrams (mg) for Resident #9, and administered the medication in his/her room. No hand hygiene was performed from the beginning of the observation at 11:11 A.M. to the end of the observation at 11:25 A.M.
During an interview on 10/30/24 at 11:25 A.M., CMT B said:
-He/She forgot to sanitize his/her hands in between the administration of the medications.
-He/She should have performed hand hygiene in between the medication administrations.
11. During an observation and interview on 10/31/24 at 8:59 A.M., CMT A began administering medications to Resident # 18. Hand hygiene was performed prior to preparing by mouth medications for the resident. CMT A prepared Aspirin (a pain reliever/anti-platelet aggregator) into the medication cup, then attempted to push a 5 mg Buspirone (a drug used to treat anxiety) tablet into the medication cup. The tablet missed the cup, landed on the medication cart and was picked up by CMT A with ungloved hands and placed into the medication cup. CMT A proceeded with the medication preparation and administered all ordered medications to the resident.
-CMT A said he/she should not have touched the medication with his/her ungloved hand after it landed on the medication cart and placed it in the medication cup for infection control reasons.
During an interview on 11/1/24 at 11:26 A.M., the DON said:
-He/She would expect hand hygiene to be performed by all staff in between medication administrations.
-He/She would expect staff to discard a medication that fell onto a medication cart and would not expect staff to pick up the medication with their hands and continue the administration.
6. Review of Resident #5's face sheet showed he/she admitted to the facility with the following diagnoses:
-Colostomy (when a piece if colon is diverted to an artificial opening in the abdominal wall) Status.
-Presence of Urogenital (relating to both the urinary and genital organs) Implants.
-Pressure Ulcer Stage III.
Review of the resident's annual MDS dated [DATE] showed:
-The resident had a catheter.
-The resident had an ostomy.
-The resident had a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer.
Observation on 10/29/24 at 9:03 A.M. of a wheelchair to bed transfer of the resident and emptied the resident's catheter bag completed by CNA C and CNA D showed both CNAs did not wear a gown the entire time they were completing the care of the resident.
During an interview on 10/30/24 at 10:56 A.M. CNA C said:
-He/She and CNA D had not worn gowns when performing the transfer and emptying the catheter bag during the resident's care.
-He/She hadn't thought about putting on a gown and just entered the room due to being nervous.
-EBP included wearing a gown and gloves during high contact resident care.
-EBP were used to protect the resident.
-Residents who have catheters, wounds, and colostomies should all be under EBP during high contact care.
During an interview on 10/30/24 at 11:04 A.M. CNA D said:
-After he/she and CNA C completed the resident's care, he/she realized that they forgot to put on gowns.
-EBP were used for general infection control purposes and was unsure of any specifics to why a resident was on EBP.
-Staff knew which residents were on EBP from a sign that was posted on the residents' door.
-The facility had bins that held the necessary PPE, and they were stationed at the end of each resident hallway.
During an interview on 10/31/24 at 1:30 P.M. the Infection Preventionist said:
-He/She had been educated on EBP and so was the rest of the staff during an in-service.
-He/She was unsure when the staff were last educated on EBP.
-EBP was used for residents with portals for infections which included wounds, catheters, gastronomy tubes (a tube that is inserted through the wall of the abdomen directly into the stomach), and any other lines in general.
-There were signs posted on each resident door that indicated the EBP and what the staff needed to wear in the room.
-The sign also indicated the type of care that would indicate the use of the gown and gloves.
-There was a cart that held the PPE on each resident hall.
-The CNAs should have used EBP while performing the residents transfer and emptying the resident's catheter bag, which included the use of gloves and gowns.
During an interview on 11/1/24 at 8:12 A.M. CNA A said EBP, which included the use of gowns and gloves, should be worn for any direct contact resident care.
During an interview on 11/1/24 at 8:24 A.M. Registered Nurse (RN) A said he/she had not been trained on EBP and was not sure what exactly EBP indicated.
During an interview on 11/1/24 at 11:36 A.M. the DON said:
-EBP included wearing a gown and gloves during direct resident care.
-There were signs posted on each residents' door that needed EBP and the sign would guide the staff on what to do.
-Residents with wounds, catheters, indicated the need for EBP.
-There was a PPE cart on each hall for the staff to utilize when EBP were needed.
-The CNAs should have worn gowns and gloves during Resident #5's transfer and when they emptied Resident #5's catheter bag.
7. Review of the facility's policy titled Tuberculosis Screening dated 11/14/16 showed:
-Upon admission, residents/guests should receive the purified protein derivative (PPD) two-step screening.
-Residents/guests may receive an annual PPD test within one week of admission anniversary test.
8. Review of the following employee records showed there was no documentation showing these employees were given a two-step TB test upon hire or that the TB testing was not completed timely upon hire or that there was a previous TB test or X-ray to rule out TB had been completed prior to employment:
-Employee A was hired 11/13/23 and his/her TB testing was started 2/5/24. He/She is still currently an employee.
-Employee B was hired 7/9/24 and there was no TB test documented. He/She is currently an employee.
-Employee C was hired 7/9/24 and there was no TB testing documented. He/She is currently and employee.
-Employee D was hired 1/12/24 and his/her TB testing was started on 3/12/24. He/She is currently an employee.
-Employee E was hired 5/20/24 and there was no TB testing documented. He/She is currently an employee.
During an interview on 11/01/24 at 8:35 A.M., Financial Assistant/Human Resources said:
-They completed an audit of the employee files in mid June 2024, and noticed there were some that were not completed and they tried to correct them.
-Upon orientation, he/she had everyone complete the TB test step 1.
-Nursing staff then complete the TB step 2 tests and they fill in the documentation.
-If there were staff who had the first TB step completed and then there was no reading, and they had to start the testing over again because the nursing staff did not get it completed (this was why some were documented late).
-They have not had a designated nurse that completed the TB testing for the past few months so whatever nurse that is available had to complete the TB testing and they were also supposed to track it to ensure both tests were completed.
-They were not able to find the TB tests on three staff sampled and he/she did not know if anyone completed their TB tests or if they just cannot be located.
During an interview on 11/01/24 at 11:36 A.M., with the DON, the Regional Nurse Consultant, and the Regional QA Nurse, the DON said:
-The nurse was to complete TB at orientation and read it 72 hours afterward then they complete second step within 10 days of the first test.
-There should not be a reason why TB was completed late.
-The staffing coordinator was responsible for ensuring the TB is completed timely, but they have not had a Staffing Coordinator and so he/she and the Infection Control Preventionist had been trying to get the TB's completed and monitor to ensure both steps were completed.
-They had recently hired a Staffing Coordinator.
-They do keep the TB records in one binder and they complete them by month so they know who needs to have their follow up
8. Review of Resident #1's face sheet showed he/she admitted to the facility on [DATE].
Review of the resident's Physician Order Sheet dated October 2024 showed:
-An order for Aplisol Solution (tuberculin PPD- used to test people for TB); five tuberculin (tub) unit/0.1 milliliter (ml); intradermal (situated, occurring, or done within or between the layers of the skin); Special Instructions: Yearly October PPD Test on October Third.
-An order for Aplisol Solution five tub. unit/0.1 ml; read only; intradermal; Special Instructions: Yearly October PPD test results Annual on October Sixth.
Review of the resident's Medication Administration Record (MAR) dated October 2024 showed:
-The test was not administered because the resident had refused.
-The results could not be read because the test was not administered.
9. Review of Resident #68's face sheet showed he/she admitted to the facility on [DATE].
Review of the resident's TB Test results on 10/31/24 showed the resident last received the test in May 2023.
During an interview on 10/31/24 at 1:30 P.M. the Infection Preventionist said:
-He/She had not kept a book or log of all resident TB test results.
-He/She used to do TB test audits, but it had been a while since the last audit was completed.
-He/She was unaware that Resident #1's TB test had not been completed.
-He/She was unaware that Resident #68's TB test had not been completed in over a year.
-Nursing Management was responsible for completing TB tests.
-Residents were to be given a two-step test upon admission, then annually thereafter.
-The nurse who was responsible for completing Resident #1's TB test should have re-offered the test or to have received an order from the facility's physician for a chest x-ray.
During an interview on 11/1/24 at 8:24 A.M. RN A said:
-Nurses were responsible for completing resident TB tests.
-He/She was unsure of who ensured the resident TB tests were completed.
-Resident TB tests needed to be done upon admission and then annually.
-If a resident were to refuse the TB test, then he/she would call the doctor to get an order for a chest x-ray to be done.
-If a resident was lasted tested for TB in May 2023, then the resident should have had the annual test completed by that point in time.
During an interview on 11/1/24 at 11:36 A.M. the DON said:
-Nurses were responsible for completing resident TB tests.
-The interdisciplinary team ensured completion of resident TB tests.
-Residents were to receive a two-step TB test upon admission and then annually thereafter.
-He/She was unaware that Resident #1 had refused his/her TB test and that the TB screening had not been completed.
-He/She was unaware that Resident #68's last TB test was completed in May 2023.
-The nurse responsible for Resident #1's TB test should have gotten an order form the facility's physician for a chest x-ray.
-Resident #68's TB test should have been done by that point in time.
Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices during wound care to prevent the potential of cross contamination for one sampled resident (Resident #9) who at risk for infection due to open wound on left buttocks area; failed to ensure enhanced barrier precautions (EBP- an approach to the use of personal protective equipment (PPE) to reduce the transmission of Multidrug-Resistant Organisms (MDROs) between residents in skilled nursing facilities) when transferring and emptying a urinary catheter (a flexible tube inserted through a narrow opening into the bladder for removing fluid) bag for one sampled resident (Resident #5), during personal care for three sampled residents (Resident #36, #68, and #59) and during a transfer for one sampled resident (Resident #19) and to ensure hand hygiene was practiced when administering medications to two sampled residents (Resident #101 and Resident #18) out of 22 sampled residents; and failed to ensure Tuberculosis (TB- a bacterial disease that mainly affects the lungs) screening was completed annually for two sampled residents (Resident #1 and Resident #68) out of five sampled residents and for 5 of 9 sampled employees. The facility census was 80 residents.
Review of the facility's policy titled Enhanced Barrier Precautions dated 4/29/24 showed:
-A sign indicated the enhanced barrier precautions should be placed on the resident's door and if it is a semi-private room, it should be labeled for which bed.
-PPE should be readily accessible at all times, preferably near or inside/outside of resident/guest rooms, shower rooms, and Therapy Gyms.
-There should be appropriate disposal containers in the resident/guest room and Therapy gyms, showers for removal of PPE.
-EBP required donning of gowns and gloves during high contact resident/guest care activities that provide opportunities for transfer of MDROs to staff hands and clothing.
-EBP was indicated for resident/guests with any of the flowing:
--Wounds or indwelling medical devices (central lines, urinary catheters, feeding tubes, and tracheostomies).
-EBP was employed while performing high contact resident/guest care activities which included:
--Dressing.
--Bathing/Showering.
--Transferring.
--Providing Hygiene.
--Changing linens.
--Changing briefs or assisting with toileting.
--Device care.
--Wound care.
1. Review of Resident #9's Significant Change of Condition Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/17/24 showed the resident:
-Was severely impaired memory for long and short term.
-Was at risk for pressure injury/ulcer (is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction).
Review of the resident's Nursing note dated 10/5/24 at 3:48 A.M., showed:
-Open wound on his/her left buttocks found by staff during cares.
-Small open area was about the size of a dime.
Review of the resident's Wound Care Plan updated 10/15/24 showed:
-Had actual skin breakdown left inner buttock.
-The resident was on Enhanced Barrier Precaution (Gown and glove are used during high contact resident care activities).
Review of the resident's Physician Order Sheet (POS) dated 10/15/24 showed a Wound Order for a Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) of sacral area (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) pressure injury, to the resident's left inner buttock.
Review of the resident's Weekly Wound Assessment Report dated 10/22/24 at 4:21 P.M., showed the resident had a wound on left inner buttocks was open and pink.
Observation on 10/29/24 at 9:37 A.M., of the resident's wound care showed:
-The resident had signage on door for Enhanced Barrier Precaution, due to his/her wounds.
-Regional Corporate Nurse with gloved hands, had unfasten and lowered the resident incontinent brief, then removed gloves washed his/her hands.
-Resident incontinent brief was dry at that time.
-The resident had a pea size open area on his/her left inner buttock.
-The Wound Nurse cleansed the wound then applied cream to the resident's clean wound area.
-Wound nurse removed the barrier and then placed the same used incontinent brief to covering the recently clean wound.
During an interview on 10/29/24 at 10:13 A.M., Wound Nurse said:
-He/She was not aware of the potential of cross contamination when reapplied the same used incontinent brief after completed wound care treatment.
-He/She should had placed a clean unused brief on the resident help protect from potential of cross contamination of the clean wound area, since no dressing applied to cover the clean wound area.
During interview 11/1/24 at 11:36 A.M., Director of Nursing (DON) and Regional Corporate Nurse said:
-He/She would expect wound nurse to ensure have a new clean brief applied after the resident wound care was completed.
-The clean brief applied would help protect the resident open wound from cross contamination from dirty to clean process.
3. Review of Resident #19's quarterly MDS dated [DATE], showed:
-The resident was alert and oriented with minimal confusion.
-Had had no functional impairment in range of motion and used a walker for mobility.
-Was dependent for toileting and required moderate assistance for upper and lower body dressing.
Observation and interview on 10/30/24 at 1:15 P.M., showed:
-There was a sign on the resident's door showing the resident was on EBP. The sign instructed the staff to stop and prior to entering the room the staff should wash or sanitize their hands, don gloves and a gown.
-There was a personal protective equipment (PPE) cart containing gowns in the hallway.
-The resident was laying down on his/her bed in his/her room.
-Certified Nursing Assistant (CNA) B entered the resident's room and without washing or sanitizing his/her hands, gowning or gloving, he/she assisted the resident to sit up on the side of his/her bed.
-CNA B then assisted the resident to the bathroom and back to his/her recliner. At 1:43 P.M., CNA B was sitting down beside the resident and was feeding him/her.
-Once he/she finished feeding the resident, he/she took his/her room tray out of his/her room without washing or sanitizing his/her hands.
During an interview on 10/30/24 at 1:24 P.M., LPN B said:
-The resident was on EBP due to an abrasion on his/her elbow.
-CNA B was supposed to wash or sanitize his/her hands prior to or upon entering the resident's room and prior to providing the resident with any assistance.
-Because the resident is on EBP, CNA B should have sanitized his/her hands, put on a gown and gloves before entering the resident's room.
-CNA B did not follow handwashing or EBP precautions.
During an interview on 10/30/24 at 1:58 P.M., CNA B said:
-Normally, upon entering a resident's room and prior to performing any cares, they are supposed to wash or sanitize their hands.
-If the resident is on EBP, they are also supposed to put on gowns and gloves if they are going to have any physical contact with the resident.
-Before exiting the resident's room they should discard their PPE and wash or sanitize their hands.
-He/She was aware that the resident was on EBP and saw the sign on his/her door.
-He/She did not use PPE or wash or sanitize his/her hands because he/she forgot to.
4. Review of Resident #68's Face Sheet showed the resident was admitted on [DATE], with diagnoses including kidney disease with dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly) use.
Review of the resident's quarterly MDS dated [DATE], showed the resident:
-Was alert and oriented without confusion.
-Was independent with mobility, dressing eating and toileting and needed supervision and touch assistance with bathing.
Observation on 10/29/24 at 9:54 A.M., showed:
-There was an enhanced barrier precaution sign on the resident's room door which instructed staff to stop, clean their hands before entering and upon leaving the room and wear gown and gloves for the following: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with device care.
-There was a PPE cart in the hallway two doors down from the resident's room.
-Upon entering the resident's room, CNA A was in the resident's room standing beside the resident who was uncovered and laying in his/her bed.
-CNA A was not wearing a gown or gloves and said he/she was providing resident care.
During an interview on 10/29/24 at 10:16 A.M., CNA A said:
-He/She had been trained on EBP but it had been a while since he/she reviewed it.
-He/She saw the EBP sign on the resident's door, but he/she really was just trying to get his/her bath completed.
-He/She thought he/she was supposed to wear a gown and gloves when a resident is on EBP, but he/she would have to read up on it again to see what the protocol was.
-He/She did not see a PPE cart outside of the resident's door but he/she did see there was one in the hallway.
-The resident was probably on EBP because of his/her wounds.
-He/She did not wear a gown or gloves prior to entering the resident's room and providing care but he/she would review the EBP protocol.
Observation and interview on 10/30/24 at 11:05 A.M., showed LPN A said he/she was going to check the resident's dialysis site. LPN A obtained his/her stethoscope and gloves went to the resident's door and knocked. Without washing or sanitizing his/her hands and donning a gown or gloves prior to entering, LPN A entered the resident's room. The resident was laying on his/her back in bed and there was a bandage over his/her dialysis access site on his/her left arm. Once LPN A finished assessing the resident he/she removed his/her gloves and washed his/her hands. LPN A said:
-Regarding EBP, the resident was on EBP due to his/her wounds.
-If anyone is in contact with his/her wound during cares, they were to wear a gown.
-Usually when someone is on EBP, anyone who is going to complete any resident care would need to wear a gown and gloves prior to contact with the resident.
-He/She said she would need to clarify if he/she was supposed to put on a gown with any direct contact with this resident.
-The nursing staff should wash or sanitize their hands upon entry into the resident's room and prior to exiting.
-He/She should have washed or sanitized her hands upon entering, but he/she put on gloves without doing so.
5. Review of Resident #36's Face Sheet showed the resident was admitted on [DATE], with diagnoses including stroke with paralysis, muscle weakness and lack of coordination.
Review of the resident's Care Plan updated 6/12/24, showed the resident needed assistance to complete daily activities of care safely. Interventions showed staff was to:
-Provide extensive assistance with bed mobility.
-Required total assistance with bathing dressing toileting and used a full body mechanical lift (a mechanical device that helps caregivers safely transfer people who have limited mobility) for transfers.
Review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was alert and oriented without confusion.
-Needed moderate to total assistance with mobility, transfers, bathing, dressing and toileting.
Observation on 10/28/24 at 11:36 A.M., showed the resident was in his/her wheelchair in his/her room. CNA F was already in the resident's room and Nurse Assistant (NA) A brought the mechanical lift into the room. Both CNA F and NA A put on gloves without washing their hands and attached the lift sling to the lift (the resident was laying on the sling) then NA A lifted the resident while CNA F assisted with moving the resident and positioning him/her in bed. CNA F and NA A removed the sling from the lift. NA A moved lift out of the room. CNA F and NA A then pulled the resident's pants down to perform incontinence care. CNA F pulled out a trash bag and placed it on the resident's bed while NA A pulled several cleansing wipes from a container, removed the resident's brief and cleaned the resident using front to back one wipe one swipe method. Both CNA F and NA A rolled the resident to the side and NA A cleaned the resident's bottom using a one wipe one swipe front to back method. NA A then, without de-gloving, washing or sanitizing his/her hands, took a clean brief and placed it under one side of the resident. CNA F and NA A rolled the resident to the left and CNA F pulled the brief under the other side of the resident. They then fastened the brief and pulled the residents pants up. CNA F and NA A both discarded their gloves and washed their hands, turning off the water with a paper towel.
During an interview on 10/30/24 at 1:58 P.M., CNA A said:
-Normally, upon entering a resident's room and prior to performing any cares, they are supposed to wash or sanitize their hands.
-They wash or sanitize their hands during care when they change gloves.
-Before exiting the resident's room they should wash or sanitize their hands.
During an interview on 11/01/24 at 11:36 A.M., with the DON, the Regional Nurse Consultant, and the Regional Quality Assurance (QA) Nurse, the DON said:
-He/She would expect nursing staff to wash or sanitize their hands before or upon entering the resident's room.
-Staff should perform handwashing or sanitizing upon entering the resident's room, during resident cares, between performing dirty to clean tasks and prior to leaving the resident's room.
Apr 2024
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
Resident Rights
(Tag F0550)
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 one sampled resident (Resident #1) was treated with dignity ...
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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 sampled resident (Resident #1) was treated with dignity and respect when on 3/25/24 Registered Nurse (RN) A cursed and yelled at the resident in the dining room out of three sampled residents. The facility census was 81 residents.
On 3/25/24 the Administrator was notified of Past Non-Compliance which occurred on 3/25/24. RN A was suspended pending investigation immediately. Upon completion of the investigation, RN A was terminated for violating facility policy on 3/26/24. Facility training for abuse, neglect, dignity and customer services was completed for all staff 3/26/24 prior to the start of their shift.
Review of the facility Resident Rights Policy dated 5/1/23 showed:
-Purpose:
--This policy is concerned with all incidents and accidents involving residents.
--All of our residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property.
--Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish.
--Verbal abuse is the use of oral, written or gestured communication or sounds that includes disparaging and derogatory term to residents or their families/representatives, or within their hearing distance, regardless of their ages, abilities to comprehend, or the nature of their disabilities by any staff member, volunteer, vendor, visitor, or other resident that is directed at the resident.
--Examples of verbal abuse include, but are not limited to: threatening to hurt and saying things to frighten a resident.
--Using profanity to a resident or ridiculing the resident are also examples that could be abuse.
1. Review of Resident #1's Face Sheet showed he/she was admitted on [DATE] with diagnoses including hyperlipidemia (high cholesterol) and presence of aortocoronary bypass graft (surgery in which a healthy blood vessel taken from another part of the body is used to make a new path for blood around a blocked artery).
Review of the resident's Care Plan dated 11/17/23 showed:
-Quality of life:
--The resident enjoys visiting with peers.
--Assist with activities to stay connected with friends.
Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 2/19/24 showed he/she was assessed to be cognitively intact and able to make his/her wants and needs known.
Review of the facility's Verification of Investigation dated 4/1/24 showed:
-Resident #1 was yelled at by RN A.
-RN A was rude and always trying to tell Resident #1 what he/she can and can't do.
-RN A has been the only staff the resident had a problem with.
-RN A attempted to throw the resident out if he/she did not do what he/she wanted the resident to do, which was to stay away from his/her friend.
-RN A was immediately suspended.
-RN A was terminated on 3/26/24 because his/her behavior violated facility policy in that he/she displayed inappropriate behavior with the public, resident, and staff.
Review of the resident's Social Service Note dated 4/3/24 showed he/she was satisfied with the things done to resolve the issue.
During an interview on 4/3/24 at 10:23 A.M. the Administrator said:
-RN A was terminated as a result of the investigation for violating facility policy.
-He/She did not feel the incident reached the level of abuse, but was not in compliance with facility policy.
During an interview on 4/3/24 at 11:01 A.M. the Social Services Director said:
-Resident #1 had become friends with another resident of the opposite gender.
-The residents would often sit next to one another and hold hands.
-RN A was concerned about the relationship between the residents due to the other resident's cognition.
-Both residents had acknowledged their friendship and the boundaries.
-There have been no concerns about any sexual behaviors.
-He/She felt RN A was attempting to protect the other resident, but went a little overboard.
-There were no concerns about a platonic relationship between the residents by the facility, family or physician.
-He/She walked into the dining room during the incident and observed RN A yelling and cussing at Resident #1.
During an interview on 4/3/24 at 12:00 P.M. Resident #1 said:
-He/She and the nurse got into it because he/she was holding hands with another resident.
-RN A came to the table, banged on the table, yelling and cursing at him/her.
-He/She just wanted everyone to get along and not be cussed out.
-The way RN A yelled at him/her made him/her feel angry.
During an interview on 4/4/24 at 10:52 A.M. RN A said:
-Resident #1 told him/her that he/she could hold anyone's hand he/she wanted.
-Resident #1 said that bitch isn't going to tell me what to do.
-He/She went to the table in the dining room and said to the resident, Well this bitch is here to protect you and everyone else.
-When he/she made the statement, the resident became more escalated and began cursing at him/her.
-The incident occurred between 7:00 A.M. and 7:30 A.M. in the dining room.
-There were four to five residents seated at the table, including the resident, at the time of the heated argument.
-He/She was terminated as a result of the situation and the allegations.
MO00233741
Mar 2024
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
Deficiency F0678
(Tag F0678)
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 ascertain the resident's code status before initiating cardiopulmon...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ascertain the resident's code status before initiating cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) for one sampled resident (Resident #5) who was a do not resuscitate (DNR) status out of 5 sampled residents. On [DATE], Registered Nurse (RN) A found the resident without spontaneous respirations and pulse and started CPR. The resident was resuscitated after CPR was performed and was taken by Emergency Medical Services (EMS) to the hospital and subsequently died [DATE] after he/she was placed on comfort care. The facility census was 79 residents.
The Administrator was notified on [DATE] at 11:25 A.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification.
Review of the facility's Cardiopulmonary Resuscitation Policy, dated [DATE], showed:
-Code Status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops).
-Original Do Not Resuscitate (DNR) Order (refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest) should be handwritten by a physician and then entered in the order system as these are not allowed to be telephone orders.
-A faxed handwritten order by physician is acceptable. The original order should be maintained in the hard copy record in a plastic sleeve.
-The DNR order is entered as a specific order type in electronic record as advance directive for quick reference in case of an emergency.
Review of the facility's undated Protocol for Emergent care showed:
-Call Stat to or Code Blue to location.
-Do not leave the resident unattended.
-Staff member should call for assistance.
-Make sure enough staff members to assist with the resident and to make all necessary phone notifications and obtain crash cart, emergency equipment.
-A staff member should access the electronic record immediately and verify the identification of the resident by electronic photograph and if there is an order for DNR. This order will appear as one of the first orders when sorting by order type. (Note does not indicate has to be a nurse or CMT).
-In electric outage a hard copy photograph used for identification and hard copy DNR order on the chart.
-The staff member (preferably nurse) that remains with the resident should get the resident prepared for resuscitation pending the determination of whether or not the resident has a current DNR order so that CPR can be immediately started if no DNR found.
1. Review of Resident #5's admission Face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses of surgical wound, low back pain, paraplegia (an impairment in motor or sensory function of the lower extremities), history of pulmonary embolism (blood clot in lung), and seizures (is a sudden body or limb jerks that can involve the arms, head and neck).
Review of the resident's admission Data Collection, dated [DATE] at 3:50 P.M., showed the resident was oriented to person, time, and situation.
Review of the resident's Base Line Care Plan, dated [DATE] at 2:04 P.M., showed the resident was a DNR, wishes no CPR.
Review of the resident's Outside the Hospital DNR Order Sheet showed the form had been signed on [DATE] by the resident and his/her physician.
Review of the resident's Physician Order Sheet (POS) showed the resident had a physician order dated [DATE] for DNR code status.
Review of the resident's Care Plan for Living Will/Do Not Resuscitate status, dated [DATE], showed:
-Goal for the resident was end of life wishes to be honored for 90 days (started [DATE]).
-Respect the resident decision and assure that he/she may change his/her mind at any time concerning terms of living will/DNR.
-Provide comfort measure and provide pain management as needed.
-Inform other healthcare providers caring for the resident of his/her living will/DNR status.
-Physician will review and uphold the resident's wishes stipulated in the living will.
Review of the resident's facility Nursing Note, dated [DATE] at 2:56 P.M. which was documented by RN B, showed:
-Around 11:30 A.M. on [DATE], the resident went unresponsive while in the bath house.
-RN B arrived to see resident already lowered to ground from wheelchair and RN A performing CPR.
-When RN B arrived at bath house at 11:32 A.M., he/she took command of recording the event.
-At 11:34 A.M., the resident had a return of spontaneous circulation (ROSC, is the resumption of sustained perfusion cardiac activity associated with significant respiratory effort after cardiac arrest).
-The resident was placed on oxygen (O2) at a rate of 15 liters via a non-rebreather mask, oxygen saturation (O2 stats- measures how much oxygen is carried by the hemoglobin in your blood) were at 95% with O2 in place, and a heart rate of 105.
-EMS arrived at 11:39 A.M., the resident was sent to the hospital for evaluation and treatment.
-The resident's family member was notified of the event.
-Note: There was no documentation the resident was a DNR status.
Review of the resident's facility Summary of Events, dated [DATE], showed:
-The resident was in the shower/bath house with two Certified Nursing Assistants (CNA) when the resident went unresponsive.
-CNA A instructed CNA B to go get the charge nurse.
-The nurse arrived at the bath house and a Code Blue (activated if a patient or individual is found unconscious, without a pulse, or not breathing) was called overhead.
-The resident was lowered to the ground and the nurse began performing CPR and staff called the emergency phone number (911).
-The facility summary timeline of the events:
--Approximately at 11:28 A.M. the resident became unresponsive.
--At 11:32 A.M., one round of chest compressions with Ambu-bag (refers to a type of device known as a bag valve mask, which is used to provide respiratory support to patients).
--At 11:34 A.M., the resident's DNR status found in orders in his/her electronic record.
--At 11:34 A.M., the resident chest compressions stopped due to ROSC achieved.
--The resident's O2 sats 66% at room air (the average O2 sats level are from 95 to 100%.) and heart rate of 121 (the normal heart rate between 60 and 100 beats/minute).
--At 11:38 A.M., resident placed on oxygen at rate 15 liters per minute via a non-rebreather mask (a special medical device that helps provide resident with oxygen in emergencies)
--At 11:39 A.M., O2 sats 95% with oxygen in place and heart rate of 105.
--At 11:39 A.M., Emergency Medical Services (EMS) arrived at the facility.
Review of the resident's EMS report, dated [DATE] at 11:34 A.M., showed.
-EMS received call from the facility related to a resident in cardiac arrest-death.
-EMS, fire and rescue arrived at the facility at 11:37 A.M.
-At 11:40 A.M., the resident vital signs were taken with findings of heart rate (pulse) of 100 beats per minute, respiratory rate of 11 (an average normal rate of 12-18 per minute), O2 sats 96% with oxygen in place, the resident had oxygen administered at flow rate of 15 liters per minute, and the resident had improved with use oxygen.
--The resident had no eye movement when assessed by EMS staff, no motor response and no verbal/vocal response.
-At 11:52 A.M., the resident departed the facility by EMS.
--At 11:58 A.M., the resident opened his/her eyes to verbal stimulation, obeys commands appropriate response to stimulation.
-At 12:06 P.M., the resident arrived at the hospital.
Narrative: dispatched to facility in regard to a cardiac arrest with CPR in progress.
-EMS unit in route and updated on the patient, he/she had regained a pulse and now spontaneously breathing. Update no longer breathing,
-An update the resident DNR status had been located.
-EMS unit arrived on scene. Resident found lying supine on the floor in the shower room. Located off the 500 hallways under the care of facility staff.
--Facility staff reports that while attempting to shower the resident, he/she became unresponsive and slumped over.
--Facility staff initiated CPR when resident was found with no pulse and no breathing observed.
--CPR was being performed by facility staff until the resident's DNR code status was located.
--The resident was unconscious and unresponsive with a Glasgow Coma Scale (GCS, is a system to score or measure how conscious you are at) of 3, he/she had a patent airway with apparent agonal (uneven) respiration at a rate of approximately 6-8 breaths per minute.
--The resident skin pink, warm and moist. The resident pupils equal and reactive to light.
-While attempting to contact online medical control for orders to transport determination, the resident began to have normal respiration and began to open his/her eyes and look around the room.
-Due to sudden increase in GCS and Level of Consciousness (LOC) transport decision were made for hospital.
-The resident was moved to a stretcher and secured in semi-Fowler (head elevated laying down) then moved to the ambulance and secured.
Review of the resident's Hospital History and Physical Assessment (H&P), dated [DATE], showed:
-The hospital received a copy of the resident's DNR status signed on [DATE].
-Family members were ok with comfort care only for the resident, to include use of a Bilevel Positive Airway Pressure (known as BPAP, or BiPAP, is a machine that helps you breathe) machine.
-Had a diagnosis of cardiac arrest (heart attack) which was witnessed while he/she was in shower room at the nursing home.
-CPR started by facility staff, even though the resident was a DNR status. Automated External Defibrillator (AED, a portable device that analyzes the heart's rhythm and delivers an electric shock to restore a normal heartbeat in cases of sudden cardiac arrest) was used.
-The resident was transferred to Emergency Department (ED) from the care facility.
-The resident had purposeful movement, but not yet following staff commands.
-The resident had Acute Hypoxic (lack of oxygen to brain) and respiratory failure (a serious condition makes it difficulty to breath on your own).
Review of the resident's hospital Physician Discharge Record, dated [DATE], showed:
-The resident was admitted to the hospital on [DATE].
-The resident had a witnessed cardiac arrest at his/her skilled facility on [DATE]. He/She had signed Outside the Hospital DNR form, but was resuscitated regardless. He/she arrived at our facility requiring BiPAP.
-He/she had a cardiac arrest event, witnessed while he/she was in the shower at nursing home.
-CPR was started, though the resident was an DNR. The facility also used an AED.
-While at the hospital, Resident #5 was able to speak for himself/herself and clearly asserted that he/she did not want any further care.
-The hospital plan was to transition the resident to hospice care, but he/she passed away prior to this occurring.
-On [DATE], the resident passed away at the hospital.
During an interview on [DATE] at 11:07 A.M., CNA B said:
-On [DATE] at around 11:30 A.M., CNA A was about to shower the resident.
-He/she had gone into the shower room to grab supplies for another resident.
-CNA A and he/she had noted the resident's head had dropped to his/her chest.
-He/she said something to CNA A that there was something wrong with the resident.
-CNA A called out the resident's name, with no response.
-CNA A then instructed CNA B to go get a nurse and he/she left to notify RN A.
-Other nursing staff also arrived at the shower house to assist in the medical emergency.
-He/she left the area to attend to another resident after he/she notified the nurse.
During interview on [DATE] at 12:27 P.M., RN A said:
-He/she was CPR certified.
-On the morning of [DATE] the resident was feeling well enough and wanted to take a shower. He/she went to the shower room with CNA A, where the resident then become unresponsive.
-RN A was notified by CNA B, and immediately went to assess the resident in the shower room.
-The resident was found unresponsive to sternal chest rub and shaking shout.
-He/she requested staff members (LPN B and CNA A) to call Code Blue and to obtain the AED and Crash cart (contains the equipment and medications that would be required to treat a patient in the first thirty minutes or so of a medical emergency).
-With assist of three other staff members lowered the resident to ground and he/she started performing chest compressions, CPR.
-Another nurse (LPN C) went to check the resident's code status and informed RN A and other nursing staff present the resident was a DNR.
-He/she stopped performing CPR after the resident had spontaneous breathing and pulse return.
-Legally he/she could not stop performing CPR once he/she started CPR. He/she could only stop CPR if the resident became responsive or EMS arrived to take over resident care.
-He/she was aware after performing CPR for a resident with a DNR, that he/she was going to be sent home until further investigation.
-His/her immediate thought was not about the resident's code status or wishes, only his/her response to an unresponsive resident and the emergency room nurse reaction kicked in and he/she started chest compressions after finding the resident had no breathing and no pulse.
-He/she should have checked for the resident's code status before performing CPR.
-The residents' code status were located in residents electronic record under POS and could also be found in the resident's medical hard chart, documented on the POS and usually a purple form with the resident's DNR form signed and dated by the physician and resident.
During an interview on [DATE] at 11:15 A.M., Licensed Practical Nurse (LPN) A said:
-On [DATE] he/she heard the Code Blue and responded to the shower house.
-RN A assessed the resident, found he/she was unresponsive, not breathing and had no pulse.
-He/she assisted RN A ad LPN B with lowering the resident to the ground.
-RN A had already started chest compressions.
-RN A was the resident's assigned nurse for that day.
-Another nurse (LPN C) entered the shower house and said the resident was DNR, stop CPR.
-The resident had started to breathe and had a pulse.
-He/she would expect the resident code status be checked prior to initiation of CPR.
Review of the facility Witness Statement by LPN B dated [DATE] showed:
-At approximately 11:30 A.M. on [DATE], he/she was informed by LPN C the facility had a Code Blue to the shower house on 500 hallway.
-As he/she was heading to the shower house, the administrator and LPN C were grabbing the crash cart.
-When he/she arrived to the shower house, he/she noted LPN A , Registered Nurse RN A and the CNA A were already on scene and RN A had already started chest compressions.
-The nursing staff transferred the resident to the ground.
-The Administrator called EMS while RN A continued chest compressions.
-He/she attached the AED pads to the resident's chest.
-At around that time I heard LPN C stating the resident was a DNR and looked up to see LPN C showing us the hard chart with the DNR order paper work.
-At around the same time the resident started breathing again, we got a set of vital signs, and then EMS arrived.
-Paramedics took over the resident's care and transported the resident to the hospital.
During an interview on [DATE] at 11:38 A.M., LPN B said:
-On [DATE] at around 11:30 A.M. he/she was informed by LPN C of a Code Blue and heard Code Blue shower room.
-The Administrator and LPN C grabbed a crash cart and headed toward the shower house by 500 hallway.
-When he/she arrived CNA A, RN A, and LPN A were in the shower room and RN A had started chest compressions while the resident was in his/her wheelchair.
-He/she and other nursing staff lowered the resident to ground with the use of a mechanical lift.
-The Administrator went to call EMS, while RN A continued CPR.
-He/she attached the pad for the AED. The resident had oxygen placed and then started using the Ambu bag.
-The Assistant Director of Nursing (ADON) was the timekeeper for the event and called out times as needed.
-At that time, he/she heard LPN C say the resident was a DNR.
-Around this time the resident started breathing again and the nursing staff obtained a set of vital signs as EMS staff arrived and took over the resident's care.
-He/she would expect the resident code status to be verified prior to performing CPR.
-The resident code status could be found by looking in his/her electronic record and then in the hard chart.
-The facility SSD had a binder with all resident DNR forms signed by the physician.
Review of the facility Witness Statement by LPN C dated [DATE] showed:
-At approximately 11:30 A.M. on [DATE], he/she was standing at the Nursing desk when he/she heard Code Blue to the shower house called overhead. I repeated the page to LPN B.
-LPN B headed to the shower house and LPN C headed to get the crash cart with the Administrator.
-Upon reaching the shower house on the 500 hallway, a crash cart was on site.
-The 500 hall charge nurse and multiple staff members were already present.
-He/she looked into the shower house to see staff lowering the resident to floor and the nurse (RN A) had started chest compressions.
-Someone called for oxygen, so I assisted unwrapping tubing and handed the to tubing to another nurse.
-He/she then heard someone ask if code status was confirmed.
-At that time, he/she sent Certified Medication Technician (CMT) A to grab the resident's hard chart.
-Another staff member called EMS while another staff attempted to reach the resident's spouse.
-CMT A returned with the resident code status, he/she called out that the resident was a DNR to the rest of nursing staff present.
-The resident had then began breathing on his/her own with noted pulse.
-CPR was stopped. EMS arrived to facility and transported the resident out of the facility.
During an interview on [DATE] at 11:22 A.M., LPN C said:
-On [DATE], heard Code Blue overhead.
-He/she had grabbed the crash cart heading to the shower house.
-Had plenty of nursing staff in the room assisting the resident.
-He/she handed the O2 tubing and then sent the CMT to get the resident's medical record.
-He/she reviewed the resident's hard chart for a physician order for DNR status, and found the resident's purple DNR order in the chart.
-He/she notified nursing staff the resident was a DNR and to stop chest compressions.
-RN A stopped CPR when the resident began to breath on his/her own and have a pulse.
-EMS arrived about the same time.
-He/she left the area to gather transfer paperwork to send with the resident to hospital.
-The resident's DNR status should have been found in his/her electronic medical record under physician orders and could also be found in the resident's hard chart, located in current printed POS.
-Located in the hard chart, should be the resident's purple DNR form, signed by the resident and his/her physician.
During an interview on [DATE] at 2:03 P.M., the admission Coordinator said:
-He/she had gone to visit the resident at the hospital on [DATE].
-The resident was found on the Intensive Care Unit (ICU) unit at the hospital.
-The resident did not have O2 in place during the visit. He/she was alert and talkative at the time the visit.
-He/she did not ask the resident about his/her feeling related to CPR being performed.
-The resident had been referred to Hospice Care Services and hospital Social Service Worker (SSW) was assisting family with finding care.
-He/She received a call about 15-20 minutes after he/she left the hospital, that the resident had passed away.
During an interview on [DATE] at 2:25 P.M., the Hospital SSW said:
-He/she was talking with the hospital physician who said the resident came to the hospital after cardiac resuscitation was successful.
-The physician and hospital had received the resident current DNR status, and the resident was placed on cardiac care monitoring only.
-The hospital Physician reported he/she had talked with the resident and he/she said Why am I here, I should not be here. (Related to his/her wishes of DNR status.)
-The resident did not want to return back to the facility, due to the facility initiated CPR not following the resident's end of life wish.
During an interview on [DATE] at 11:56 A.M., Hospital Physician B said:
-The resident expressed his/her intent of not wanting CPR performed while at the hospital.
-The resident came in with the Out of Hospital DNR form.
-The resident was admitted to the hospital to provide comfort care only.
-He/she was made aware the facility had initiated CPR even though the resident had a code status of DNR.
-The resident passed away at the hospital on [DATE].
During an interview on [DATE] at 2:18 P.M., Physician A said:
-He/she was the resident's physician.
-He/she was made aware of the change of condition and the incident related to not following the resident's wishes for DNR.
-It was reported the facility staff could not find the resident DNR status right away and started chest compressions, CPR.
-He/she felt it could have been worse, if the facility found out the resident was full code and did not start CPR.
-He/she felt the facility should ensure a better system was in place for obtaining or access resident code status.
-The resident passed away at the hospital.
During an interview on [DATE] at 3:09 A.M., Director of Nursing (DON) said:
-He/she would expect the nursing staff to follow facility policy for verifying DNR status by checking the resident's electronic record first for current DNR physician order.
-The resident DNR status can also be found in the residents' hard chart under current printed physician order sheet and front of the chart purple form, signed by resident and the resident physician.
-He/she would expect the nursing staff to obtain the resident code status before initiation of CPR chest compression.
-He/she would expect nursing staff to complete initial assessment of the resident by checking for responsiveness, pulse and breathing, while another nurse would obtain and check code status before initiation of CPR.
-RN A was aware of Resident #5's code status. He/she entered the resident's DNR code status physician order into his/her electronic record on [DATE].
-RN A's instincts were to ensure he/she immediately addressed the resident's medical emergency which the resident was without a pulse, not breathing, and was unresponsive.
-RN A's thought was the resident not breathing and had no pulse, he/she needed start chest compressions (CPR).
During interview on [DATE] at 11:36 A.M., CMT A said:
-He/she was not aware if CMTs had access to the resident physician orders to review the resident code status.
-He/she would have obtained the resident's hard chart for the resident code status and given to the nurse to review.
-He/she was not shown how to find the resident code status in physician orders in the electronic records.
During an interview on [DATE] at 11:40 A.M., LPN D said:
-He/she would assess the resident and have another nurse or CMT find the resident code status.
-To find a resident DNR status he/she would go into the electronic charting to find the DNR orders.
-He/she not sure if the CMTs had access. After review of the facility electronic records, the CMT was able to access the resident physician orders.
During an exit interview on [DATE] at 12:20 P.M., the DON said:
-Licensed nursing staff was required to be CPR certified and would be responsible for initiating CPR after nursing staff had checked and verified the resident code status.
-CPR should not be initiated until verified the resident end of life wishes or DNR status.
-CMTs and nursing staff should have access to check code status in the resident electronic record under physician orders.
-CNAs would be instructed to grab the hard chart for the nursing staff to find and verify the resident's code status.
-He/she would expect CMTs and nursing staff to have the capability and knowledge to know how to locate the resident code status in the electronic medical record, to find printed copy signed DNR form and the physician order located in the resident medical hard chart.
During an interview on [DATE] at 12:30 P.M., the Administrator said:
-He/she would expect nursing staff to follow the facility policy and verify the resident code status before initiation of chest compressions or CPR.
-The first nurse assessing the resident while the second nurse checked the resident code status.
-RN A did not verify the resident code status prior to initiation of CPR.
-RN A was not thinking about having to check the resident's code status first.
-RN A's first reaction when he/she responded to residents' emergency, was to be assessed, the resident required immediate emergency care and he/she initiated CPR due to the resident was unresponsive, not breathing and had no pulse. He/she was not thinking about checking code status first.
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. The facility put measure in place to ensure the deficient practice with CPR would not recur. 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).
Complaint# MO 00233192
Mar 2023
12 deficiencies
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 have a correct code status for a one sampled resident (Resident #26...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a correct code status for a one sampled resident (Resident #261) out of 14 sampled residents. The facility census was 55 residents.
Record review of facility policy Advance Directives and Refusal of Treatment-Missouri dated [DATE] showed:
-The resident had the right to refuse treatment, to refuse to participate in experimental research and to formalize and advanced directive for the management of his/her care.
-The resident might have refused medical treatment to the extent permitted by law.
-Only when the resident's medical status and the resident's or family's wishes indicated can a Do Not Resuscitate (DNR) be completed.
-This could be at any point in the resident's care.
-This form would be placed in the front of the medical record housed in a plastic sheath.
-Orders would be written in the physician section of the medical record.
-The physician have to enter the order personally, no orders for DNR can be taken via telephone, but fax or email orders were acceptable.
-Upon the resident's admission to the facility, the Social Services designee would obtain from the resident or the resident's family a copy of any declarations.
-The purpose for the Do Not Resuscitate Orders was to clearly enunciate the circumstances under which a physician may enter a DNR order into the resident's medical record.
-DNR orders a physician's order that heroic or extraordinary means would not be employed on behalf of a resident under his/her care in the event a resident is found with no vital signs.
-The facility can enter a DNR order into the medical record if the resident has consulted with his/her Attending Physician who has documented in the resident's medical record the he/she had explained to the resident and the resident understood his/her illness and the probable consequences of refusing Resuscitation.
-In the case of a resident who requested entry of a DNR Order, permission from the resident would be sought to explain to the resident's Family and the Facility's intention to abide by that decision.
-An Out of Hospital DNR form would be completed by the resident and signed by the attending physician or a physician chosen by the resident.
-The DNR form would be printed.
-If a Resident gave unrescindend Oral or Written Directions regarding entry of a DNR Order to a care giver after being advised by his/her Attending Physician of the consequences of a DNR order and the residents became incapacitated, the resident's directions remain valid unless revoked.
-When a DNR order was decided upon the DNR Order would be entered in the resident's medical record.
1. Record review of Resident #261's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed the resident had a BIMS (brief interview for mental status) score of 6, which indicated the resident had a severe cognitive impairment.
Record review of the resident's Face Sheet showed the resident was readmitted to the facility on [DATE] with the following diagnoses:
-Generalized anxiety disorder (a mental condition characterized by excessive or unrealistic anxiety about two or more aspects of life (work, social relationships, financial matters, etc.), accompanied by symptoms such as increased muscle tension, impaired concentration, and insomnia.).
-Chronic obstructive pulmonary disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation.).
-History of falling
-Difficult in walking.
-No code status was listed.
Record Review of the resident's undated New Admit form showed that the resident wanted to be a DNR.
Record review of the resident's Physician Orders dated [DATE] showed no DNR order for the resident.
Record review of the resident's Departmental Notes dated [DATE] showed resident wanted to be a DNR but no paperwork in place.
Record review of resident's Care Plan dated [DATE] showed the resident's code status was not addressed in the care plan.
On [DATE] a copy of the resident's DNR form was requested from the Director of Nursing (DON) and not provided.
During an interview on [DATE] at 9:28 A.M., Registered Nurse (RN) A said:
-Code status was given in report and if the resident was a DNR it would be in the electronic medical record once the physician signed the form.
-The code status if it was a DNR would be in the electronic medical record, and the signed form would be in the resident's paper chart.
-The resident was a full code and had always been a full code, the resident had never mentioned that he/she wanted to be a DNR.
-Advance directives and code status were discussed on admit.
-Code status was established on admit, and if a resident was a DNR and had an outside the hospital DNR form signed it would be valid until physician signed the facility form.
-When a resident wanted to be a DNR he/she would get a copy of the facilities DNR form and would have the resident sign it and send it to the doctor.
-Once the facility form was signed by the doctor an order would be placed into the chart and in the electronic medical record.
-When he/she received report from the hospital on the resident, the nurse at the hospital said the resident wanted to be a DNR.
-He/she asked the hospital nurse during report if there was a signed DNR form, and the hospital nurse said no.
-It was facility policy that all residents are a expected to a be full code unless documented.
-Code status are given in report and all DNR'S were in the computer.
-The nurse that actually admitted the resident would do the DNR paperwork once the resident was admitted to the facility in case the preference was changed.
-He/she was going to wait for the resident to be admitted to the facility and then if the resident still wanted to be a DNR would have initiated the steps to make the resident a DNR.
-The resident was admitted to the facility after he/she left for the day, so he/she passed on to the oncoming nurse that the hospital indicated that the resident was a DNR.
-When he/she worked the following day, he/she saw there was no DNR order for the resident.
-He/she asked resident his/her code status and the resident indicated he/she wanted to be a full code. However he/she did not document that conversation.
-It was the admitting nurse's responsibility to get the DNR process started.
During an interview on [DATE] at 9:48 A.M., Certified Nursing Assistant (CNA) D said:
-He/she did not know the residents' code statuses.
-He/she would ask the nurse the code status.
-He/she was unaware of the residents code status.
-He/she would call for a nurse if a resident was found unresponsive, since he/she was not certified for Cardiopulmonary Resuscitation (CPR an emergency lifesaving procedure performed when the heart stops beating).
-If a resident was found unresponsive he/she would call for a nurse.
-He/she was not currently not CPR certified but would be in the next class.
-Code status is not given in report.
-All residents were considered a full code unless told different.
During an interview on [DATE] at 11:04 A.M. Interim DON said:
-When a resident wants to be a DNR, and did not already have a DNR form signed, the expectations was that Social Services would go and talk to the resident in a timely manner that day or the next day if the admission occurred after Social Services left for the day.
-Social Services would then verified that it was the resident's wish.
-Social Services would then facilitate the DNR request between the resident, physician, and nursing to get the facility DNR form signed.
-Once the resident and physician have signed the form the orders is placed in the resident's chart, and an order is placed in the computer.
-It was his/her expectation that these steps would have been done and a DNR order would have been placed in the chart until resident changed his/her mind.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to notify the resident's responsible party after a fall occurred for one sampled resident (Resident #10) out of 14 sampled residents. The faci...
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Based on interview and record review, the facility failed to notify the resident's responsible party after a fall occurred for one sampled resident (Resident #10) out of 14 sampled residents. The facility census was 55 residents.
On 3/13/23 the Administrator was notified of the past noncompliance which occurred on 2/18/23. On 2/19/23 the facility administration was notified of the change of condition/notification not being completed and a grievance was started. Facility staff were educated on change of condition and notification to the responsible party. All changes of condition were monitored daily for notification. The deficiency was corrected on 2/20/23.
Record review of the facility policy Change in Medical Condition dated 11/28/16 showed:
-Notification of the resident's family member should occur promptly when there is a change in the resident's medical condition.
-Example of a change of condition was a fall.
1. Record review of Resident'#10's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed but facility staff for care planning )dated 2/7/23 showed the resident:
-Was severely cognitively impaired.
-Was independent with transfers, bed mobility and ambulation.
-Did not have any falls.
Record review of the resident's Nurses Notes dated 2/18/23 at 2:14 A.M. showed:
-The resident was found lying on the floor on his/her back while walking to the restroom.
-The resident was assessed and had a laceration to his/her right eye and no other injuries.
-There was no documentation the resident's responsible party was notified.
Record review of the resident's incident report dated 2/18/23 showed:
-The resident was found lying on the floor on his/her back while walking to the restroom.
-The resident was assessed and had a laceration to his/her right eye and no other injuries.
-The resident's physician was notified.
-There was no documentation the resident's responsible party was notified.
Record review of the resident's Nurses Notes dated 2/20/23 showed:
-The resident's responsible party was at the facility and was upset.
-He/she had not been notified of the resident's fall.
-The resident's responsible party wanted to be notified of any changes night or day.
Record review of the resident's fall care plan updated 2/20/23 showed:
-The resident was at risk of falls.
-The resident had a recent fall on 2/18/23.
-Nighlights were installed in the resident's room to assist with toileting.
During an interview on 3/15/23 at 5:43 A.M. Licensed Practical Nurse (LPN) D said:
-If a resident fell or had a change of condition, the nurse was responsible for notification of the resident's responsible party.
-If the resident had an injury, the responsible party should be called immediately even if in the overnight hours.
-If the resident had no injuries, the responsible party should be notified in the morning.
During an interview on 3/15/23 at 8:06 A.M. the Clinical Care Coordinator said:
-The resident had a family member visit and saw the resident's laceration and bruising and contacted the resident's responsible party.
-The resident's responsible party came to the facility on 3/20/23 and was irate.
-The responsible party had not been notified of the resident's fall.
-He/she wanted to be notified day or night if there was any change of condition.
-The nurse was responsible for notification of the resident's responsible party.
During an interview on 3/15/23 at 8:45 A.M. the Interim Director of Nursing (DON) said:
-The nurse was responsible for notifying the resident's responsible party of the resident's fall.
-The nurse did not notify the resident's responsible party of the fall.
-He/she had been made aware of the situation and immediately in-serviced the nurse one on one.
-All other nursing staff were educated regarding notification.
MO00214429
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two sampled residents (Residents #6 and #50) who remained in the facility b...
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Based on interview and record review, failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two sampled residents (Residents #6 and #50) who remained in the facility but were discharged from Medicare part A services for beneficiary notices. The facility census was 55 residents.
A policy was requested from the facility but not received.
1. Record review of Resident #6's SNF ABN Protection Notification Review showed:
-The resident went on hospice (end of life care) per family request on 3/12/23.
-A SNF ABN was not provided to the resident or resident's responsible party.
2. Record review of Resident #50's SNF ABN Protection Notification Review showed:
-The resident was discharged off Medicare Part A services on 12/2/22.
-A SNF ABN was not provided to the resident or resident's responsible party.
3. During an interview on 3/16/23 at 8:53 A.M. the Financial Analyst said:
-He/she was responsible for completing all notices when a resident discharged off of Medicare Part A services.
-He/she had not been providing the SNF ABNs to the residents or resident's responsible party at all.
-He/she had not been told to provide this form to residents.
-He/she was unaware the SNF ABN form for Medicare Part A discharges needed to be provided to all residents who remained in the facility.
During an interview on 3/17/23 at 11:01 A.M. the Interim Director of Nursing (DON) said:
-The Financial Analyst was responsible for completing all notices related to Medicare Part A discharges.
-He/she was not involved with these forms.
-The Regional Financial Analyst would be responsible for monitoring any Medicare Part A discharge forms.
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 (a resident advocate who provides support 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 notify the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) for one closed record resident (Resident #58) of his/her discharge from the facility out of three closed record sampled residents. The facility census was 55 residents.
A policy was requested and no policy was received related to notification of the ombudsman.
1. Record review Resident #58's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 12/22/22 showed the resident:
-Was severely cognitively impaired.
-Was admitted for skilled rehabilitation services.
Record review of the resident's Discharge summary dated [DATE] showed:
-The resident was being transferred to another facility.
-The resident was sent to the other facility with all medications.
During an interview on 3/16/23 at 1:40 P.M. the Social Services Designee (SSD) said:
-He/she was responsible for notifying the Ombudsman of all discharges and transfers from the facility.
-He/she notifies the Ombudsman on a monthly basis.
-He/she had not notified the Ombudsman of the resident's discharge.
-He/she had missed this notification.
During an interview on 3/17/23 at 11:01 A.M. the Interim DON said:
-The SSD was responsible for notifying the Ombudsman of all discharges from the facility on a monthly basis.
-The SSD should have notified the Ombudsman of the resident's discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the follow-through of the Pre-admission Screening and Resident Review (PASRR) recommendations and to integrate the recommendations i...
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Based on interview and record review, the facility failed to ensure the follow-through of the Pre-admission Screening and Resident Review (PASRR) recommendations and to integrate the recommendations into the care plan for one sampled resident (Resident #50) out of 14 sampled residents. The facility census was 55 residents.
A policy was requested but not received.
1. Record review of Resident 50s admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/24/22 showed the resident:
-Was severely cognitively impaired.
-Had the following diagnoses:
--Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety)
--Depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable).
--Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others).
-Did not have a PASRR.
Record review of the resident's Level II PASRR dated 2/3/23 showed:
-The resident had the following diagnoses:
--Bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).
--Schizophrenia.
--Schizoaffective disorder: a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.
--Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-The dementia diagnosis was not considered primary at this time.
-Had a long history of mental illness and psychiatric treatment since the 1980s.
-Had a recent hospital stay for mental health issues and was in a catatonic (a group of symptoms that usually involve a lack of movement and communication, and also can include agitation, confusion, and restlessness) state.
-Was appropriate for long-term care placement.
-Required the facility to provide:
--A behavioral support plan including monitoring.
--Medication therapy and monitoring: psychiatric care and medication management, medication management, monitoring for adverse side effects of medications, monitoring of therapeutic effect in managing mental health including laboratory services, address refusal and implement plan to manage resident refusals of medications, provide education/training in drug therapy management.
--Structured environment: provide personal space, provide for sensory supports, provided consistent routines with daily activities, assess and plan for the level of supervision required to prevent harm to self or others, provide instructions on resident's level of understanding.
--Activities of Daily Living (ADL's-activities related to personal care) program: develop a program for grooming, dressing, personal hygiene, toileting, and bathing.
Record review of the resident's care plan on 3/14/23 showed there was no PASRR integrated care plan.
During an interview on 3/16/23 at 1:08 P.M. MDS Coordinator said:
-He/she was responsible for updating and creating care plans.
-He/she had not received a PASRR for the resident to integrate into the resident's care plan.
-If a resident had a Level II PASRR, this should be integrated into the care plan.
-The Social Services Designee (SSD) was responsible for providing the PASRR to him/her.
During an interview in 3/16/23 at 1:40 P.M. the SSD said:
-He/she received the residents' Level II PASRRs and would review these.
-He/she filed these in his/her office.
-He/she did not provide the Level II PASSR to the MDS Coordinator or nursing staff.
-He/she was not aware the Level II PASRR needed to be integrated into the care plan.
During an interview on 3/17/23 at 11:01 A.M. the Interim DON said:
-When a Level II PASRR was received for a resident, the SSD was responsible to notify nursing.
-Nursing was responsible for ensuring the Level II PASRR was integrated into the care plan.
-The resident should have an integrated care plan based off the level II PASRR.
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 F0661
(Tag F0661)
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 complete a recapitulation upon discharge form the facility for one clo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed complete a recapitulation upon discharge form the facility for one closed record resident (Resident #58) out of three closed record sampled residents. The facility census was 55 residents.
Record review of facility policy entitled Discharge Summary and Plan of Care dated November 28, 2016 showed:
-Appropriate discharge planning and communication of necessary information to the continuing care provider, after discharge of a resident from the facility, help the new care provider to understand the resident's goals and needs.
-When the facility anticipated the discharge of a resident, a discharge plan summary would be developed.
-Upon discharge of a resident a discharge summary was provided to the receiving care provider.
1. Record review Resident #58's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 12/22/22 showed the resident:
-Was severely cognitively impaired.
-Was admitted for skilled rehabilitation services.
Record review of the resident's Discharge summary dated [DATE] showed:
-The resident was being transferred to another facility.
-The resident was sent to the other facility with all medications.
Record review of the resident's electronic medical record on 3/14/23 showed no recapitulation of the resident's stay.
During an interview on 3/16/23 at 12:49 A.M. Licensed Practical Nurse (LPN) B said:
-When a resident discharged from the facility, he/she completed a discharge transfer form.
-Nursing staff did not complete the recapitulation of stay.
-He/she was not exactly sure who completed the recapitulation of stay but it might be the Social Services Designee (SSD).
During an interview on 3/16/23 at 1:18 P.M. Infection Control Preventionist said when a resident discharged from the facility, the nurses were responsible for completing the recapitulation of stay.
During an interview on 3/16/23 at 1:40 P.M. the Social Services Designee (SSD) said:
-He/she did not complete the recapitulation after a resident discharged from the facility.
-The nurses were responsible for completing the recapitulation of stay.
During an interview on 3/17/23 at 11:01 A.M. the Interim DON said:
-He/she expected the nurses to complete a recapitulation of the residents' stay upon discharge.
-The recapitulation was not completed for the resident.
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 ensure physician's order for oxygen tubing changes wer...
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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 physician's order for oxygen tubing changes were on the Physician's Orders Sheet (POS) and to ensure oxygen nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose in a sanitary manner) and tubing was stored to prevent contamination when not in use for two sampled residents (Resident #49 and #51); to ensure nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) equipment was maintained and stored to prevent contamination when not in use for one sampled resident (Resident #49); and to ensure an oxygen care plan was completed for one sampled resident (Resident #51) out of 14 sampled residents. The facility census was 55 residents.
Record review of the facility's Nebulizer policy dated 5/1/04 showed:
-The staff were to obtain physician's orders for the nebulizer.
-After use of the nebulizer and cleaning of the nebulizer, store the equipment in a plastic bag.
Record review of the facility policy Oxygen Administration dated 12/8/05 showed:
-Physician's orders should be obtained for oxygen use.
-The nasal cannula and mask should be changed weekly.
-The nasal cannula should be stored in a plastic bag when not in use.
1. Record review of Resident #49's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 2/7/23 showed the resident:
-Was moderately cognitively impaired.
-Was on oxygen.
Record review of the resident's care plan last updated 2/27/23 showed the resident:
-Used oxygen therapy.
-Needed his/her oxygen tubing changed per facility protocol.
Record review of the resident's POS dated 3/2023 showed:
-Dated 12/30/22: Administer oxygen at 2-4 liters per nasal cannula as needed for shortness of breath.
-Dated 12/30/22: Administer ipratropium 0.5 milligrams (mg)-albuterol: give one vial via inhalation per nebulizer as needed every 6 hours for shortness of breath/Congestive Heart Failure (CHF-disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body).
-There were no physician's orders to change the nasal cannula/tubing or the nebulizer mask/tubing.
Observation on 3/13/23 at 10:51 A.M. showed:
-The resident's nebulizer was on the end of his/her bed. His/her nebulizer tubing was lying on the bed with the nebulizer mask on the top of the nebulizer.
-The resident's nasal cannula and tubing was hanging over the top of the oxygen concentrator. The humidifier bottle was half full and not dated.
During an interview on 3/13/23 at 10:53 A.M. the resident said:
-The staff do not bag his/her tubing, mask or nasal cannula.
-This was how it was left daily.
Observation on 3/13/23 at 12:01 P.M. showed:
-The resident's nebulizer was on the end of his/her bed. His/her nebulizer tubing was lying on the bed with the nebulizer mask on the top of the nebulizer.
-The resident's nasal cannula and tubing was hanging over the top of the oxygen concentrator. The humidifier bottle was half full and not dated.
Observation on 3/14/23 at 8:16 A.M. showed:
-The resident's nebulizer was on the end of his/her bed. His/her nebulizer tubing and mask were lying on the bed.
-The resident's nasal cannula and tubing were coiled up and set inside the handle of the oxygen concentrator not covered. The humidifier bottle was not dated.
Observation on 3/14/23 at 1:28 P.M. showed:
-The resident's nebulizer was on the end of his/her bed. His/her nebulizer tubing was lying on the bed with the nebulizer mask on the top of the nebulizer.
-The resident's nasal cannula and tubing were coiled up and set inside the handle of the oxygen concentrator not covered. The humidifier bottle was not dated.
Observation on 3/15/23 at 7:57 A.M. showed:
-The resident's nebulizer was on the end of his/her bed. His/her nebulizer tubing was lying on the bed with the nebulizer mask on the top of the nebulizer.
-The resident's nasal cannula and tubing were coiled up and set inside the handle of the oxygen concentrator not covered. The humidifier bottle was not dated.
2. Record review of Resident #51's admission MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Did not use oxygen.
Record review of the resident's care plan dated 1/31/23 showed no care plan for oxygen use.
Record review of the resident's POS dated 3/2023 showed:
-Dated 1/30/23: Administer oxygen at 2-4 liters per nasal cannula as needed for shortness of breath.
-There were no physician's orders to change the nasal cannula or tubing.
Observation on 3/13/23 at 12:50 P.M. showed:
-The resident's oxygen tubing was on the floor between the bed and oxygen concentrator.
-The resident's nasal cannula and part of the tubing were wrapped around the enabler bar on the resident's bed.
-The humidifier bottle on the oxygen concentrator was not dated.
Observation on 3/14/23 at 1:47 P.M. showed:
-The resident's oxygen tubing was lying on top of the oxygen concentrator with the nasal cannula was in the handle.
-Part of the resident's oxygen tubing was on the floor.
-The water bottle was not dated.
During an interview on 3/14/23 at 1:47 P.M. the resident said:
-The staff do not store any of the tubing or nasal cannula in a bag.
-The staff changed the tubing and nasal cannula one time when it was clogged and there was no oxygen flow.
3. During an interview on 3/16/23 at 12:24 P.M., Certified Nursing Assistant (CNA) C said:
-All Oxygen tubing and nasal cannulas were to be stored in a bag when not in use.
-Nebulizers should not be on the bed and stored on the table with a barrier.
-All nebulizer masks and tubing should be stored in a plastic bag when not in use.
-The nurses replace the humidifier bottles.
-CNAs were responsible for ensuring all tubing, nasal cannulas and masks were stored in bags when not in use.
During an interview on 3/16/23 at 12:49 A.M. Licensed Practical Nurse (LPN) B said:
-The resident should have physician's orders for changing out oxygen tubing, nasal cannulas, masks and humidifier bottles.
-These should all be changed weekly on the night shift and documented on the nurses Medication Administration Record (MAR).
-The nurse should hang a plastic bag and date the plastic bag should when the oxygen tubing, nasal cannulas, and masks were changed.
-The CNA's were responsible for ensuring the oxygen tubing, nasal cannulas, and masks were placed in the plastic bags when not in use.
-The nurses were responsible for dating the humidifier bottles when changed.
-Nebulizers should not be stored on the resident's bed and should be put away on the night stand.
-The residents did not have physician's orders for when to change the oxygen tubing, nasal cannulas, masks and humidifier bottles.
-When the nurse writes the physician's orders for oxygen, he/she was responsible for ensuring orders were written to change the equipment weekly.
During an interview on 3/16/23 at 1:08 P.M. MDS Coordinator said:
-He/she was responsible for updating care plans.
-He/she reviewed notes about the residents in the morning daily to see if care plans needed to be updated.
During an interview on 3/17/23 at 11:01 A.M. the Interim Director of Nursing (DON) said:
-The charge nurses were responsible for ensuring the oxygen tubing, nasal cannulas, and masks were placed in the plastic bags when not in use.
-All storage bags should be changed when visibly soiled.
-The nurses were responsible for obtaining orders to change out the oxygen tubing, nasal cannulas, and masks on a monthly basis.
-The nurses were responsible for changing and dating the humidifier bottles.
-The resident's oxygen tubing, nasal cannulas, and masks should have been stored in plastic bags when not in use.
-If the resident was on oxygen the MDS Coordinator was responsible for updating the residents care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
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 bed rails were assessed on an on-going basis, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure bed rails were assessed on an on-going basis, to try other assistive devices before placing the side rails, to have a consent signed by the resident to notify them of the risks and/or benefits of the use of side rails and to care plan the use side rails for one sampled resident (Resident #43) out of 14 sampled residents. The facility census was 55 residents.
Record review of the facility policy Bed Rail Use dated 10/26/22 showed:
-Bed rails may be used to enable a guest to become more functionally independent and when their medical condition required to use of a bed rail.
-Bed rails may be used to help turn themselves in bed.
-Possible hazards and clinical benefits of the bed rail use should be explained to the resident during the admission process and upon initial implementation of the bed rails.
-The bed rail evaluation should be completed upon admission, readmission, when implementing the side rail, with significant change and with the Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff) (quarterly).
1. Record review of Resident #43's Face Sheet showed he/she was admitted to the facility on [DATE] and had a diagnosis of a stroke.
Record review of the resident's 1/9/23 quarterly MDS showed the resident:
-Was cognitively intact.
-Required the extensive assistance of two staff members for bed mobility.
Record review of the resident's Care Plan updated 2/22/23 showed the resident:
-Needed extensive assistance for bed mobility.
-Did not have a care plan for the use of bed rails.
Record review of the resident's electronic medical record on 3/15/23 showed no documentation of any bed rail assessments.
Observation on 3/13/23 at 9:38 A.M. showed the resident was lying in his/her bed and had a ½ side rail up on each side of the upper part of his/her bed.
Observation an interview on 3/13/23 at 10:32 A.M. showed:
-The resident was lying in his/her bed and had a ½ side rail up on each side of the upper part of his/her bed.
-The resident lowered the head of the bed to a flat position.
-The resident was lying flat in the bed and used his/her hands over his/her head to reach up to the bed rail and reposition him/herself.
-This was difficult for the resident.
-He/she had asked the staff for a trapeze (a piece of medical equipment that is used to help patients who are unable to move on their own get in and out of bed. The trapeze consists of a bar that is attached to the bed frame and can be lowered or raised as needed) over his/her bed so he/she did not have to put the bed flat to move him/herself around.
-He/she did not remember who he/she had talked with about the trapeze.
-He/she felt a trapeze would work better for him/her.
-The bed rails had been placed on his/her bed a while ago but did not know the circumstances of why they were placed instead of a trapeze.
Observation on 3/14/23 at 8:22 A.M. showed the resident was lying in his/her bed and had a ½ side rail up on each side of the upper part of his/her bed.
Observation on 3/15/23 at 7:59 A.M. showed the resident was lying in his/her bed and had a ½ side rail up on each side of the upper part of his/her bed.
During an interview on 3/16/23 at 12:49 A.M. Licensed Practical Nurse (LPN) B said:
-Nurses did not complete any bed rail assessments.
-The bed rail assessments were completed by the Infection Control Preventionist and/or the Director of Nursing (DON).
During an interview on 3/16/23 at 1:08 P.M. MDS Coordinator said:
-If a resident had ½ bed rails up on his/her bed this should have been added to the resident's care plan.
-He/she was not aware the resident used any bed rails.
During an interview on 3/16/23 at 1:18 P.M. Infection Control Preventionist said:
-The bed rail assessment was completed by the therapy department.
-Nursing management would also completed the bed rail assessments.
-The facility used enabler bars for the residents and not side rails.
-The least restrictive device should be used first before using side rails.
-He/she was not sure who obtained signed consents of the resident for the risks and benefits for the use of side rails.
During an interview on 3/16/23 at 2:04 P.M. Physical Therapist A said:
-The therapy department did not place side rails on the residents' beds or assess for the use of bed rails.
-The resident had been on their caseload twice and bed rails had not been placed by therapy.
-He/she was not aware of how the resident obtained the bed rails.
During an interview on 3/17/23 at 11:01 A.M. the Interim DON said:
-The resident did not have any bed rail assessments completed for the use of bed rails.
-The nursing management staff was responsible for completing the bed rail assessments.
-The bed rail assessments contain informed consent on the form.
-He/she thought the resident had ¼ bed rails and not ½ bed rails.
-He/she was unsure how the resident obtained ½ side rails on his/her bed.
-The care plan should reflect the use of the side rails/enablers and the MDS Coordinator was responsible for care planning.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #6's Face Sheet showed he/she was readmitted to the facility on [DATE] and had diagnoses that inclu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #6's Face Sheet showed he/she was readmitted to the facility on [DATE] and had diagnoses that included:
-Hypertensive Heart Failure disease (high blood pressure) patients with chronic kidney disease stage 1-4 (means your kidneys are damaged and can't filter blood the way they should. The disease is called chronic because the damage to your kidneys happens slowly over a long period of time. This damage can cause wastes to build up in your body).
-Acute (sudden) kidney failure (end-stage renal disease- is the inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes).
-Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait).
Record review of the resident's Hospice Medical Record binder showed:
-The last documentation of Comprehensive Nursing Visit summary note was dated 9/2/21.
-NOTE: The resident's hospice record did not have a current documentation of ongoing comprehensive nursing assessment to evaluate the quality and appropriateness of hospice services furnished to hospice patients under their agreement.
-The last recorded Certified Nursing Assistant (CNA) visit was documented 2/20/23.
-Hospice Certification and Plan of Care had certification Benefit was updated on 2/23/23.
-He/she had a signed Outside of the Hospital DNR status form.
-Had a skilled nursing visit on 3/13/23 included vital signs and no new orders if any order.
Record review of the resident's Quarterly MDS dated [DATE] showed the resident:
-Received hospice services.
-Was severely cognitively impaired.
Record Review of the resident's POS dated 3/2023 showed;
-The resident had a physician order dated 3/12/23 to be admitted under hospice care for diagnosis of End Stage Heart Failure.
-Physician order for Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) was dated 3/9/23.
During an interview on 3/15/23 at 11:25 A.M., Hospice Licensed Practical Nurse (LPN) A said:
-After the visit and assessment he/she gave a verbal report to the charge nurse and advised the charge nurse of any changes or new orders.
-He/She could not print off information in the facility, so the reports would be printed off and brought in on next visit.
3. During an interview on 3/15/23 at 12:45 P.M., Registered Nurse (RN) A said:
-The hospice nurse always reported off verbally to them of any changes or new orders once the visit was completed.
-The hospice nurse did not have access to the facilities network and could not print off the hospice documents.
-Hospice company was supposed to bring in documentation and place in the book on the next visit.
-Hospice kept the nurse informed of all changes with the residents so he/she did not look in the hospice book.
-If he/she had any questions, he/she would review the last visit note in the hospice binder and if needed call the hospice nurse.
-He/She could not show any current visits notes.
During an interview 3/17/23 at 10:52 A.M., Interim Director of Nursing (DON) said:
-He/she would expect to see up to dated hospice documentation of the collaboration of care, nursing visit notes, hospice plan of care located in the resident hospice medical record.
-Would expect to have up to date nursing visit summary in chart. A team effort from charge nurse to DON to review books to make sure all information were in the resident hospice binder.
-Would expect to have a current hospice nurse comprehensive assessment/visit summary located in the resident's hospice book.
-Hospice staff would be responsible for ensuring the resident's hospice binder had most current information from the hospice visit and updated hospice plan of care.
Based on interview, and record review, the facility failed to ensure documentation of coordination of care with hospice (end of life care) services by not ensuring a current hospice comprehensive resident medical record was maintained with a current certificate of care, nursing summary, and plan of care for two sampled residents (Resident #29 and Resident #6) out of 14 sampled residents. The facility census was 55 residents.
A policy related to hospice services was requested and not received at the time of exit.
Record review of the facility and specific Contracted Hospice Agency Agreement dated 10/13/22 showed:
-Each party shall prepare and maintain complete and detail clinical record concerning each hospice resident receiving hospice services under this agreement in accordance with it usual record -keeping procedures and as required by applicable federal.
-Each record shall have document that the specified services are furnished in accordance with this agreement and shall be readily accessible and systematically organized to facility retrieval by either party.
-Hospice shall develop, maintain and conduct ongoing comprehensive assessment to evaluate the quality and appropriateness of hospice services furnished to hospice patients under this agreement, hospice shall cooperate with facility in conduct of facility quality assessment and assurance committee as it relates to hospice patients.
-Hospice will document that hospice services are furnished in accordance with this agreement.
1. Record review of Resident #29's admission Face sheet showed he/she was admitted to the facility on [DATE] and had diagnoses that included:
-Hypertensive Heart Failure disease (is a common complication in hypertensive(high blood pressure) patients with poor prognosis and is a leading cause of kidney disease) with kidney failure (end-stage renal disease- is the inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes).
-Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).
-Was on hospice care.
Record review of the resident's Hospice Medical Record binder showed:
-Hospice Certification and Plan of Care had certification benefit from 6/5/22 to 9/2/22.
-The last documentation of Comprehensive Nursing Visit summary note was dated 6/5/22.
-NOTE: The resident's hospice record did not have a current documentation of a ongoing comprehensive nursing assessment to evaluate the quality and appropriateness of hospice services furnished to hospice patients under their agreement.
--Did not have hospice documentation of transfer of another facility for care and treatment on 9/1/22.
Record review of the resident's Care Plan, dated 9/2/22, showed the resident:
-Had been admitted to hospice services.
-Did not have an admitting hospice diagnosis documented.
-Had interventions for the facility to coordination the resident care and services with hospice staff related to end of life care to assure the resident experiences as little pain as possible.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) tracking record dated 9/7/22 showed the resident:
-Was admitted to facility while on hospice services.
-Was cognitively intact and had a history of short and long term memory loss.
Record review of the resident's hospice medical record binder showed:
-He/she had an Outside Hospital DNR status form was signed on 9/14/22.
-Hospice had documentation in resident's hospice binder an audit tool completed on 1/5/23.
-NOTE: The resident's hospice record did not have a current documentation of a ongoing comprehensive nursing assessment or visit summary of visit.
--Did not have hospice documentation of transfer of another facility for care and treatment on 9/1/22.
Record review of the resident's Nursing Note dated 2/10/23 at 3:14 P.M. showed:
-Hospice speech therapist completed an evaluation related to the resident diet change from regular diet to mechanical soft. The resident was not to use straws and nursing were to continue to crush all medication.
-The resident's family member were made aware of the changes.
Record review of the resident's Quarterly MDS dated [DATE] showed the resident:
-Was mildly cognitively impaired and had a history of short and long term memory loss.
-Was on hospice services.
Record review of the resident's Physician's Order Sheet (POS) dated 3/2023 showed;
-The resident had a physician order dated 10/6/22 to be admitted under hospice care for diagnosis of Hypertensive Heart Failure with kidney failure.
-The resident physician order for Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) was dated 11/30/22.
Record review of the resident's hospice medical record binder showed:
-Hospice staff hand written Coordination of Visit Notes showed;
--He/she had hospice skilled nursing visit note on 3/9/23, 3/7/23, 3/13/23 and 3/23/23. included vital signs and if any order changes.
--The most current hospice Home Health Aide visit was on 3/10/23. Had documentation that the resident had a bed bath with all cares completed.
-NOTE: The resident's hospice record did not have a current documentation of a ongoing comprehensive nursing assessment or visit summary.
During an interview on 3/15/23 at 10:11 A.M., Licensed Practical Nurse (LPN) B said:
-He/she not aware of the resident having any detailed Hospice Nurse Summary visit report provided.
-The hospice nurse would complete paper communication sheet and notify the facility charge nurse of any new orders or concerns for the resident.
-the resident was being seen by hospice and have not had any recent changes noted.
-He/she would notify the hospice staff of any resident change of condition and would have documented findings in the resident nursing note.
During an review and interview 3/15/23 at 11:57 A.M., with Infection Control Preventionist (ICP) said:
-He/she had to call get a complete updated hospice record to include current nursing summary visit report.
-The resident's hospice binder should include the most recent comprehensive hospice record to include current care plan and nursing summary visit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure resident funds were placed in an account separate from the facility's operating account whereby, not providing and returning residen...
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Based on interview and record review, the facility failed to ensure resident funds were placed in an account separate from the facility's operating account whereby, not providing and returning residents' their personal refunds from the operating account in a timely manner for 34 residents (Resident #190, #18, #160, #161, #162, #163, #41, #202, #164, #165, #166, #167, #203, #168, #29, #192, #170, #13, #171, #172, #173, #174, #177, #178, #179, #180, #181, #182, #183, #184, #186, #187, #188 and #189). The facility had a census of 55 residents at the time of survey.
1. Record review of the facility's maintained Interim Aged Analysis Summary (Accounts Receivable Aging Report) for the period 3/1/22 through 3/31/23, showed the following residents with personal funds held in the facility's operating account.
Resident Amount Held in Operating Account
#190 $ 323.99
#18 $ 81.00
#160 $ 164.61
#161 $ 26.92
#162 $ 32.88
#163 $ 166.78
#41 $ 130.00
#202 $ 2,154.35
#164
$ 4,305.23
#165 $ 633.00
#166 $ 2,472.78
#167 $ 1,308.54
#203 $ 906.00
#168 $ 905.32
#29 $ 2,911.97
#192 $ 394.00
#170
$ 6.50
#13
$ 2,977.70
#171
$ 525.63
#172
$ 2,208.06
#173
$ 821.31
#174
$ 36.00
#177
$ 200.00
#178
$ 5,745.50
#179
$ 1,203.00
#180
$ 5,508.54
#181
$ 998.20
#182
$ 250.00
#183
$ 630.66
#184
$ 1,655.00
#186
$ 1,146.39
#187
$ 2,294.19
#188
$ 78.00
#189
$ 2,847.50
Total $46,049.55
During an interview on 3/15/23 at 10:15 A.M., the Business Office Manager said he/she:
-Started in that position a little over a year and was working on cleaning up the past due credits and accounts.
-Will make that a priority in the upcoming weeks to resolve the credits in the residents' accounts.
-Has a meeting with his/her Regional staff on 3/28/23 to discuss the facility's receivable aging accounts.
During an interview on 3/16/23 at 3:36 P.M., the Administrator said he/she was surprised at the amount of credits in the aging accounts receivables and would work with the Business Office Manager to resolve and clean up the accounts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure Nurse Aide (NA) Registry checks, Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or...
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Based on interview and record review, the facility failed to ensure Nurse Aide (NA) Registry checks, Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) checks, Family Care Safety Registry (FCSR-helps to protect long-term care residents by providing background information on employees or prospective employees) checks, Employee Disqualification List (EDL) checks, and/or Criminal Background Check (CBC) checks were completed prior to hire for three sampled staff (Employees A, D, and F) out of 10 sampled staff. The facility census was 55 residents.
Record review of the facility's Employment policy and procedure 10/22/98 showed:
-An offer of employment may be made by the department head/supervisor only after the following checked:
--Applicable registry, licensing board, etc. has been contracted and checked.
--The criminal background check completed and are satisfactory.
--The policy did not address specific to checking EDL, CBC, FCSR, or the NA registry.
1. Record review of Employee A's file showed:
-He/she was rehired on 2/11/22.
-There was no record of the NA Registry being checked prior to or upon hire.
-There was no current CBC requested or received upon rehire.
-The last CBC on file was dated 9/8/17.
2. Record review of Employee D's file showed:
-He/she was hired on 12/07/22 and started working on 12/12/22.
-There was no record of the NA Registry being checked prior to or upon hire.
3. Record review of Employee F's file showed:
-He/she was hired on 1/12/23 and started working on 1/25/23.
-The NA Registry had been checked after hire on 3/15/23.
-The FCSR and CBC requested and received on 3/16/23.
During an interview on 3/17/23 at 9:39 A.M., Human Resource (HR) said:
-He/she would have completed a NA Registry check for all new staff hired.
-He/she was not aware a NA Registry check should be completed for rehired staff.
-Employee A was a rehire and he/she was not aware it was required to complete a CBC and NA registry for rehired or transferred employees.
-For Employee D, he/she had just missed running the NA report for this employee.
-Employee F, he/she was not able to find documentation for employee checks so, he/she reran the all the background checks again.
-Employee F did not start on hire dated listed.
During an interview on 3/17/23 at 9:39 A.M., Administrator said:
-The facility cooperate compliance office, would have been responsible for audits of all employee files to include reviewing for new hire required background checks.
During an interview 3/17/23 at 10:52 A.M., Interim Director of Nursing (DON) said:
-The facility DON or staff developing coordinator and HR were responsible for ensuring all new employees had required documentation to include background checks were completed upon hire and annually.
-HR staff were responsible for ensuring the criminal back ground checks all prior to hire,
-The new employees are able to start employment as long as they had their initial criminal background checks started prior to hire. When the results come in, if noted any criminal activity or other issue with the background checks, then the new employee would be pulled from the work schedule.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have a Facility Assessment updated annually and as nee...
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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 have a Facility Assessment updated annually and as needed to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community-based risk assessment updated annually and complete to show the current resident population and needs. A total of 14 residents were sampled. The facility census was 55 residents.
Facility policy for facility assessment was requested from the facility and no policy was provided.
1. Record review of the Facility Assessment dated 12/17/2021 showed:
-Casper Report dated 10/31/21 was used for information for the assessment.
-Facility Census and Condition report competed 10/31/21 was used for the report.
-Facility Matrix dated 10/31/21 was used for the assessment.
-Provider Rating Report Nursing Home Compare Five-Star Rating dated 10/31/21 was used for the assessment.
-Resident Electronic Charting System report dated 10/31/21 was used for the assessment.
-Current staffing was stable from day to day and shift to shift based on the normal and expected care needs of the resident on each unit.
-Did not vary staffing levels according to prospective resident's acuity or care needs, but admit or refuse residents based on the estimation of whether the facility an meet the needs with the existing staff.
-The facility assessment did not address COVID (a new disease caused by a novel (new) coronavirus) and the requirements of this disease.
-There was limited information regarding all areas required.
-The facility admitted the following type of residents:
--Cardiac (heart) disease/rehabilitation.
--Residents with contagious (infectious diseases that spread from person to person) disease/condition management.
--Wound management.
--Intravenous (within the vein) (IV) therapy.
--Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses)/Alzheimer's (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception)(memory unit)
--Dementia/Alzheimer's (not on special unit) and with antipyschotic (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis)medications.
--Other residents that received psychotropic (drugs which affect psychic function, behavior, or experience) medications.
--Post Stroke recovery on anti-coagulant (slows blood clotting)therapy.
--Post stroke recovery that received therapy.
--Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile).
--Orthopedic recovery/fractures (broken bones)/amputations (severing), joint replacements.
--Parkinson's (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait)Disease.
--Swallowing disorders.
--Enteral feeding (nutrition administered through a feeding tube).
--Fall risks.
--Respiratory disorders/Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation)/ bilevel positive airway pressure (BiPAP a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing).
--Tracheotomy (surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions).
--Residents who smoked.
--Pain management.
--Palliative care/Hospice.
--Peritoneal (the space within the abdomen that contains the intestines, the stomach, and the liver) dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood).
--Hemodialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein).
--Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
--Full Code residents.
--Adults under [AGE] years of age.
--Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine)/suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) /urostomy (an operation to create an opening from inside the body to the outside, making a new way to pass urine)/ostomy (artificial or surgical opening) residents.
--Therapy including physical, occupational, speech, and respiratory.
Record review of facility Resident Census and Conditions of Residents dated 3/13/23 showed the facility had the following residents:
-Eight with Foley or S/P catheters.
-Seven with contractures (an abnormal usually permanent condition of a joint, characterized by flexion and fixation).
-Two that had an intellectual and/or developmental disability.
-25 with documented signs or symptoms of depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-30 residents with psychiatric (pertaining to or within the purview of psychiatry, the medical specialty concerned with the prevention, diagnosis, and treatment of mental illness) diagnosis
-21 with Dementia.
-11 with behavioral healthcare needs.
-Two with Pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction).
-Seven receiving hospice services.
-Three on dialysis.
-Seven with respiratory treatments.
-One tracheostomy.
-One ostomy.
-One that required suctioning.
-Two with Enteral (tube) feedings.
-Eight with mechanically altered diets.
-13 that received therapy.
-36 that received psychoactive medications.
-Five that received antibiotics.
-33 on a pain management program.
Observation on 3/13/23 thru 3/17/23 of the facility showed the following types of residents:
-Tracheotomy residents.
-COVID positive residents.
-Residents that required Physical Therapy, Occupation Therapy, and Speech Therapy.
-Residents that required tube feedings.
-Residents that required oxygen therapy.
-Residents on hospice.
-Residents that require dialysis.
-Residents with cognitive defects.
During an interview on 3/17/23 at 9:50 A.M. the Administrator said:
-He/she was new and there were some things that were not completed.
-The last facility assessment was to be completed yearly and as necessarily.
-The facility assessment should be based current information,
-The previous Administrator should have updated the facility assessment annually and as needed.
-The facility assessment should have reflected the current population of the residents.
-COVID was just like the Influenza and would be treated like that.
Dec 2022
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
Deficiency F0761
(Tag F0761)
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 lock the medication cart or the narcotics cart, allowi...
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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 lock the medication cart or the narcotics cart, allowing an unknown individual to take a medication card of 28 Percocet 5/325 milligram (mg) (a Schedule II narcotic medication used to treat severe pain, and required by law to be locked behind two locks at all times when not in use) tablets, belonging to one sampled resident (Resident #1) out of three sampled residents, from the narcotics box, and the medication card was never located. The facility census was 69 residents.
On 12/23/22 the Administrator was notified of the past noncompliance which had begun on 12/10/2022. The facility administration was notified of the incident and the investigation was started. Facility employees were reeducated on policy and procedure with return demonstration. Audits were completed of the medication carts. The deficiency was corrected on 12/11/22.
Record review of the facility's policy for Controlled Medication Storage dated 03/2011 showed:
-Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations.
-The Director of Nursing (DON) and the consultant pharmacist were to maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.
-Only authorized licensed nursing and pharmacy personnel have access to controlled medications.
-Controlled medications were to be stored under double lock in a locked drawer/cabinet or safe designated for that purpose, separate from all other medications.
-The medication nurse on duty was to maintain possession of the key to the controlled medication storage box/areas.
-A controlled drug record was prepared when receiving or checking in a controlled medication if not provided with the narcotic.
-The controlled drug record was to include the name of the resident, prescription number, name, strength, dosage form, date received, quantity received, and the name of the person receiving the medication supply.
-At change of custody, a physical inventory of all controlled medications was conduct and documented by two licensed nurses.
-Any discrepancy in controlled substance medication counts was to have been reported to the DON immediately.
-The DON then was to have begun an investigation, making every reasonable effort to reconcile all reported discrepancies.
1. Record review of Resident #1's facility Face Sheet showed he/she was admitted [DATE] with the following diagnoses:
-Chronic pain syndrome (persistent pain that lasts days to years).
-Cellulitis of his/her left and right lower limbs (a bacterial infection of the skin).
Record review of the resident's Physician's Order Sheet (POS) dated 4/19/22 showed he/she was to receive Percocet 5/325 mg by mouth every day at bedtime and every four hours as needed for pain.
Record review of the resident's Nursing Care Plan dated 4/19/22 showed:
-He/she had the potential for pain.
-He/she was to have no unrelieved pain for the 90 days review period.
-The facility staff was to coordinate with the physician to manage his/her pain medication for optimum pain control.
-The facility staff was to observe for the effectiveness of the pain medications.
Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 11/30/22 showed he/she:
-Was mostly cognitively intact.
-Had no issues with mood.
-Had delusions (misconceptions or beliefs that are firmly held, contrary to reality).
-Required limited assistance of one staff member for transferring and walking.
-Required extensive assistance of one staff member for dressing and toileting.
-Was independent with eating and personal hygiene.
Record review of the facility's Verification of Investigation dated 12/10/22 showed:
-The incident occurred on 12/10/22 at 6:30 P.M.
-During shift change medication count, a discrepancy was determined that resulted in a missing medication card.
-An investigation was initiated by the Director of Nursing (DON).
-The nurse interviews determined the involved nurse failed to always secure his/her medication cart.
-The nurse in charge of that cart was drug tested and suspended pending the investigation.
-Immediate in-services were initiated for all staff with access and performing medication administration.
-An audit was performed and no other discrepancies were discovered.
-The involved nurse had no previous history or disciplinary actions related to medication administration.
-The resident had an additional card of the medication that was available, so no doses were missed.
-The missing card of 28 tablets of Percocet 5/325 mg was replaced at facility cost.
-The resident missed no doses.
-Department of Health and Senior Services was notified.
-Pharmacy was notified and participated in the investigation.
-Local law enforcement was notified.
-The physician was notified that no doses were missed and the physician had no additional recommendations.
-The resident's family was notified and had no concerns.
-Abuse/misappropriations in-services with staff was started on 12/10/22.
-Residents who were interviewed had no reports of missing medications on all wings.
-Staff interviews determined no concerns of the same of similar nature.
-Audits were completed on all narcotics determined no other discrepancies.
-The facility medication book audits were performed with no other concerns.
During an interview on 12/21/22 at 11:00 A.M., the DON said:
-He/she was called at 6:30 P.M., on 12/10/22 by Licensed Practical Nurse (LPN) A.
-LPN A stated that during the narcotics count, it was discovered that a card of 28 Percocet for Resident #1 was missing from the locked narcotic box.
-LPN A further stated the page which corresponded with the card of Percocet been ripped out of the narcotics book.
-The DON instructed Registered Nurse (RN) A to tell all staff to stay in the building and to not exchange any medication cart keys and he/she would be right into the facility.
-He/she further instructed the staff to search the trash cans, shred boxes, medication room and anywhere else they thought of to ensure the card of Percocet was truly missing.
-The same nurses who counted on the evening of 12/10/22 had counted the morning of 12/10/22.
-The morning of 12/10/22, Resident #1 had a full card of 30 Percocet tablets and a second card of 28 Percocet tablets.
-The resident had not received any Percocet during the day shift and had none scheduled until 9:00 P.M., on 12/10/22.
-When he/she questioned RN A about locking his/her cart, RN A stated he/she was sure that he/she had forgotten to lock the cart.
-When RN A was questioned about how the narcotic box was not locked, RN A told the DON that he/she thought he/she did not latch the narcotic box completely closed the last time he/she got out a narcotic.
-When the DON asked about where the narcotic book had been placed during the shift, RN A told him/her that the book had been on the nurse's station desk instead of locked inside the medication cart where it was supposed to be placed when not in use.
-During the staff search for the Percocet card, LPN A found the top of the page which corresponded with the 28 Percocet and was used for re-ordering, inside the shred box located under the nurse's station desk.
-When the DON got to the facility, he/she and the nursing staff did a full audit of all narcotics to ensure that no other narcotic was missing.
-He/she then began the investigation and began educating all nursing staff regarding locking the medication carts, narcotic boxes and placing the narcotic book locked inside the medication cart.
Observation on 12/21/22 at 11:25 A.M., showed the page which would have corresponded with the 28 Percocet was clearly ripped out of the narcotic book.
Observation on 12/21/22 at 11:28 A.M., showed:
-The narcotic box did not automatically lock.
-In order to lock the narcotic box, the nurse had to push down on the narcotic box lid until the lid latched in place and locked.
During an interview on 12/22/22 at 10:15 A.M., LPN A said:
-He/she had counted the morning of 12/10/22.
-The count on the morning of 12/10/22 had been correct with no missing narcotics.
-When they counted the evening of 12/10/22 and found the missing Percocet, he/she thought maybe the card had just been placed in the wrong place in the narcotic box, but after checking every card, the card of 28 Percocet was definitely missing.
-He/she also discovered that the sign-out page corresponding with the 28 Percocet had been ripped out of the book.
-He/she and RN A called the DON and followed his/her instructions.
-LPN A discovered the top of the Percocet sign-out page, used for re-ordering, in the shred box located under the nurse's station desk.
During an interview on 12/21/22 at 10:40 A.M., RN A said:
-He/she and LPN A had counted the same medication cart the morning on 12/10/22 and there were no discrepancies.
-At first, they thought the card of 28 Percocet had just been misplaced when he/she got busy during the day shift.
-He/she and LPN A immediately called the DON when they discovered the narcotic was really missing.
-He/she knew that there was a card of 30 Percocet and a card of 28 Percocet for Resident #1 when he/she began his/her shift.
-He/she also knew that he/she gave no Percocet to Resident #1 during the day shift.
-He/she took full responsibility as he/she knew that he/she got busy during the day and did not lock the medication cart or latch the narcotic box completely shut, allowing easy access for anyone to take the card of 28 Percocet as that particular card had been in the very front of the narcotic box.
-LPN A located the top of the narcotic sign out page for the 28 Percocet in the nurse's station shred box.
-The DON notified the police and they came to check in, he/she gave the top of that narcotic sign-out page to the police officer.
-The police did not do anything except take the page from him/her, as they said there was really no way of knowing who took the narcotic.
During an interview on 12/21/22 at 12:22 P.M., Certified Nursing Assistant (CNA) A said:
-He/she did not see anyone hovering around that medication cart during his/her shift on 12/10/22.
-With it being a weekend close to the holidays, there were a lot of visitors there that day and some groups of people came and brought gifts to the residents.
During an interview on 1/4/22 at 10:40 A.M., the Acting DON said:
-He/she would have expected the nursing staff to have locked the medication cart with the narcotic sign-out book inside and latch the narcotic box fully, ensuring the narcotic box locked.
-He/she had not seen any staff who appeared to be under the influence of any narcotic.
-He/she believed that the narcotic was taken but it would be impossible to determine who took it.
During an interview on 1/4/22 at 11:45 A.M., the Administrator said:
-He/she would have expected the nursing staff follow the appropriate policy/procedure for maintain the integrity of the narcotics.
-He/she felt the facility would never know what happened to the card of 28 Percocet.
MO00211045
Oct 2020
22 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #63's Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #63's Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's Care Plan dated 10/23/19 and updated on 9/12/20 showed:
-He/she was at risk for falls.
-Staff were to encourage clutter-free environment and path to the bathroom.
-Staff were to assist the resident with ambulation, toileting and mobility as needed.
Record review of the resident's Nurse Notes dated 9/6/20 showed:
-The resident fell while walking down the 400 Hall toward the nurse's desk.
-The CMT saw the resident fall.
-The CMT reported the resident hit his/her head on the wall and his/her elbow on the floor.
-The resident reported he/she was not hurt at that time.
-Staff assisted the resident to his/her feet and walked him/her to his/her bed.
-The nurse noticed the resident's right elbow was out of shape and started to swell.
-He/she notified the resident's physician and obtained orders to send the resident to the hospital.
-The resident's family was also notified.
Record review of the resident's Nursing admission Review dated 9/8/20 showed:
-The resident was readmitted to the facility after a hospital stay.
-The resident fractured his/her right elbow from a fall on 9/6/20.
-The resident had a splint.
Record review of the resident's annual MDS dated [DATE] showed he/she:
-Was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15.
-Was independent with transfers, toileting, personal hygiene, walking and eating.
-Required staff supervision with dressing.
-Required extensive staff assistance with bathing.
-Had limited Range of Motion (ROM) with impaired mobility in his/her upper extremities on one side.
-Used a walker and wheel chair.
-He/She had no falls since admitted .
Record review of the resident's medical record showed:
-No documentation an incident report was initiated or completed after the resident's fall with a fracture on 9/6/20.
-No documentation staff completed a fall investigation, including completing neurological checks after the resident's fall with a fracture on 9/6/20, when he/she was known to have hit his/her head.
-No documentation a fall risk assessment was completed after the resident's fall with fracture on 9/6/20.
During an interview on 10/22/20 at 12:25 P.M., the resident said:
-He/She fell in his/her room.
-He/She was wearing house shoes when he/she fell.
-He/She fractured his/her right arm from the fall and had to go to the hospital.
During an interview on 10/26/2020 at 11:15 AM , LPN A said:
-He/She was not on shift when the resident fell.
-Information about the resident's fall would be found in the resident's electronic medical chart.
-If neurological checks were completed, staff would document them in the resident's electronic medical record.
During an interview on 10/27/20 at 1:19 P.M., the DON said:
-Staff should have completed an incident report and investigation after a resident has a fall, including if the fall was witnessed.
-Neurological checks should have been completed if a resident hit his/her head.
-The nurse would initiate the incident report and investigation, but the management team would complete the fall investigation.
-Fall risk assessments should be completed quarterly and as needed by the MDS Coordinator.
2. Record review of Resident #64's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Major depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Stroke.
Record review of the resident's annual MDS dated [DATE] showed he/she:
-Was cognitively intact.
-Was totally dependent on two staff members for transfers.
Record review of the resident's Nurses Notes dated 11/8/19 showed:
-It was noted this afternoon while getting the resident from his/her wheelchair to bed with a Hoyer lift (A hydraulic pump is used to lift the person off the bed surface. Once the person is suspended in the air, the Hoyer lift can be maneuvered to a wheelchair or another surface by pushing the lift on its wheels) the resident's foot got caught on the lift and the resident had immediate complaints of pain.
-The resident's physician was notified and X-ray orders were obtained to X-ray the resident's left foot and left knee.
-The DON and the resident's responsible party was notified.
-The resident would continue to be monitored at this time.
Record review of the resident's Nurses Notes dated 11/9/10 showed:
-The resident's X-rays of his/her left foot and left knee showed no significant change or injury.
-The resident had bone demineralization (the loss, deprivation, or removal of minerals or mineral salts from the body, especially through disease) and Degenerative Joint Disease (DJD-gradual wearing down of the bones and joint surfaces causing pain and swelling at the affected areas).
-There were no significant changes of the resident's left foot and left knee condition when this X-ray was compared to the resident's last X-ray.
Record review of the resident's care plan updated 3/20/20 showed he/she needed the assistance of two staff members for transfers with the use of a Hoyer lift.
Record review of the resident's annual MDS dated [DATE] showed he/she:
-Was cognitively intact.
-Was totally dependent on two staff members for transfers.
During an interview on 10/19/20 at 11:05 A.M. the resident said:
-He/she had been transferred with a Hoyer lift and his/her foot got caught during the transfer about six months ago.
-This hurt his/her knee but it did not break his/her bones.
Record review on 10/20/20 of the resident's electronic medical record showed there was no incident report completed by the staff.
During an interview on 10/27/20 at 9:38 A.M., Licensed Practical Nurse (LPN) B said:
-If an injury occurred to a resident, the nurse was responsible for completing and incident report and notifying the resident's physician and family.
-If a resident had a potential injury during a Hoyer lift transfer, an incident report should be completed.
During an interview on 10/27/20 at 10:08 A.M., LPN A said he/she was not sure if an incident report needed to be completed if a resident had a potential injury from a Hoyer lift transfer.
During an interview on 10/27/20 at 12:16 P.M. the ADON, the DON, and the Regional Nurse Consultant (previously the interim DON) said:
-He/she expected the nurse to complete an incident report if a resident's foot was potentially injured during a transfer.
-Management was responsible for investigating further based on the incident report.
-An incident report should have been completed for the resident.
Based on observation, interview and record, the facility failed to ensure a resident with a history of falls from bed received adequate supervision, care and interventions to keep him/her safe from injury and emotional harm after he/she had numerous falls, including a fall from his/her bed after which he/she yelled out in a distressed manner and was found lying on the floor mattress next to his/her bed, face down, with his/her head stuck between the floor mattress and bedframe, resulting in redness on his/her neck and face, and he/she continued to vocalize in a distressed manner for 30 minutes after he/she was found, and to notify the resident's physician and guardian for one sampled resident (Resident #49); to complete an incident report and investigation after a resident had a fall for two sampled residents (Resident #49 and #63); and to complete an incident report and investigation when a resident had his/her foot caught during a staff assisted transfer resulting in complaints of pain for one sampled resident (Resident #64) out of 17 sampled residents. The facility census was 68 residents.
Record review of the facility Change in Medical Condition or Resident policy dated 10/1/10 showed:
-The purpose of the policy was to keep the physician who is in charge of medical care, and family members/legal representatives, responsible for health care decisions and other resident decisions and other resident representatives informed of the resident's medical condition so they may direct the plan of care as needed.
-Notification of the physician, legal representative, or interested family member should occur promptly according to Federal regulations, when there is a change in the resident's condition.
-Change in condition is defined as:
--An accident involving the resident which results in injury and has the potential for requiring physician intervention.
--A significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening conditions of clinical complications).
--A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to communicate a new form of treatment).
-Assess the injury or change in condition and determine whether it is an emergency medical situation or a non-emergency situation.
-Contact the physician and family/legal representative for an emergency at the time the event occurs whatever time of day or night.
-In non-emergency, call during normal office and daylight hours.
--If a non-emergency situation occurs after 5:00 P.M. or on a weekend or holiday, the physician is contacted the next day or at the schedule requested by the physician, but no later than the next day.
-When possible, non-emergency calls are consolidated with routine calls.
-The 24 Hour (a shift to shift communication between licensed nurses to update residents' conditions and care needs and document any changes in residents' status) shift report can be used as a reminder for an oncoming shift to notify a physician and/or family member.
-The Director of Nursing (DON) may be consulted for assistance determining the urgency of calls.
-Document the symptoms and observations associated with the change in condition, the dated and time of contact with the physician and family member/legal representative.
-Notes also should include comments on the care provided by nursing personnel.
-The 24 Hour report served as a reminder to report any change in condition to the oncoming shift.
-Further assessment may be warranted with certain permanent changes in condition.
-The plan of care may be altered to reflect a change in condition where new goals and approaches are developed.
Record review of the facility Incidents and Accidents policy dated 8/26/20 showed:
-The purpose of the policy was to keep the resident's environment as free of accident hazards as possible.
-Prompt reporting and response to accidents was to occur.
-Examples of incidents included resident fall/found on floor.
-Handling accident occurrences included-
--The resident should not be moved unnecessarily until his/her condition has been assessed
--Assess the resident for pain, range of motion, bruising, bleeding and lacerations (a skin/tissue cut or tear).
--Access the resident for neurological signs (assessment for problems with nerve, spinal cord, or brain function) as appropriate.
--Notify the physician, obtain orders for care, including any indicated diagnostics (use of a device or substance used for the analysis or detection of diseases or other medical conditions).
--Notify family of the accident, status and orders for the residents care.
-Remember, fractures in the elderly, particularly the immobile or contracted (reduction in normal joint range of movement caused by drawing together/shrinking of muscles/tendons) elderly, cannot readily be detected visually; frequently the elderly do not experience pain or deformity (misshape) immediately after a fracture.
-Interventions should be documented in the nurse's notes and the incident noted on the 24 Hour Report.
-An incident/Accident report should be completed.
-Develop a brief investigation plan, include obvious interviewees, questions to be asked and information to be gathered.
-Be sure to include documentation of interviewee and interviewer, with date, time and place on the statement.
-Be sure to note if interview was face to face or by phone; it is preferable to interview face to face whenever possible.
-Initiate and investigation.
1. Record review of Resident #49's Face Sheet showed he/she was admitted to the facility on [DATE] and his/her diagnoses included:
-History of falling.
-Paraplegia (an impairment in motor or sensory function of the lower half of the body).
-Unspecified convulsions (seizures).
-Muscle contractures (muscle tightening or shortening causing a deformity resulting in pain and loss of movement of joints).
Record review of the resident's hospital medical records dated 7/11/19 showed:
-He/she was non-verbal.
-He/she had a history of strokes and a motor vehicle accident (MVA) in 2013 with axonal injury (the tearing of the brain's long connecting nerve fibers that happens when the brain is injured as it shifts and rotates inside the bony skull; it usually causes coma and injury to many different parts of the brain) with severe neurological deficits.
-Diagnosis, Assessment and Plan included that he/she had agitation (anxiety or nervous excitement), was on as needed (PRN) Ativan (antianxiety medication), and was at high risk of climbing out and falling out of bed.
Record review of the residents annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/20/20 showed:
-He/she was cognitively impaired.
-He/she had absence of spoken words.
-He/she had behavioral symptoms.
-He/she required extensive two person assistance for bed mobility.
-He/she was totally dependent on two or more staff for transfer.
-He/she had non-verbal sounds of pain.
-He/she had not had falls since completion of the previous MDS (Note the resident had experienced falls).
Record review of the residents Falls Care Area Assessment (CAA - the process of focusing on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored) for his/her 3/20/20 comprehensive assessment showed:
-He/she received antipsychotic, antianxiety, antidepressant and opioid (formerly known as narcotic) medications.
-History of falling was blank, physical performance limitations was blank.
-Internal risk factors included incontinence, seizure disorder, paraplegia, cognitive impairment, and anxiety.
-Environmental factors was blank.
-Analysis of findings contained a statement that the resident was dependent for transfers from two staff and a mechanical lift, he/she was known to slide out of bed at times, he/she was unable to make his/her needs known and his/her bed was in the lowest position with mats on the floor.
-Note: there was no documentation of the frequency of finding him/her out of his/her bed, of alternatives considered to keep the resident safe, of a potential for him/her to become stuck/wedged by his/her bed frame and no evidence of a complete analysis of causative factors related to his/her falls.
Record review of the resident's care plan reviewed on 4/26/20 showed:
-He/she would had a need for safety and would be kept away from aggressive residents.
-He/she had a potential for complications related to anticoagulant (blood thinner) therapy.
-He/she had a potential for complications related to anxiety state.
-Staff were to explain care and procedures before and during care, provide support and reassurance as needed, and observe for nervous, anxious fidgeting behaviors.
-He/she had paraplegia, contractures, was unable to perform self-care and required total assistance from staff.
-There were no interventions address his/her specific need for individualized assistance devices and number of staff needed to transfer (move from one surface to another surface) him/her.
-He/she had a potential for falls related to moving about in his/her bed and wiggling in his/her chair.
-Staff were to observe his/her need for additional assistive devices/positioning devices, keep his/her bed in the lowest position and provide a mattress beside his/her bed.
-He/she often rolled onto the mattress beside his/her bed and then onto the floor.
-Staff were to monitor him/her at all times when he/she was up in his/her wheelchair so that he/she did not wriggle to the end of his/her chair and cause it to tip forward.
-Note: There were no individualized interventions to keep the resident safe and free from bodily/emotional harm from falls and/or from his/her body being entrapped by his/her bed.
Record review of the resident's Nurse's Progress Note dated 5/31/20 at 5:21 P.M. showed:
-The licensed nurse heard the resident yelling out in a distressed manner and found him/her laying on his/her mattress next to his/her bed, face down with his/her head stuck between the mattress he/she was laying on and the frame of his/her bed.
-The licensed nurse got a Certified Nursing Assistant (CNA) who helped safely get the resident back into his/her bed.
-The resident was crying and seemed to be extremely upset.
-The licensed nurse consoled the resident and was able to calm him/her.
-The licensed nurse then completed an assessment and noted that the resident had red markings on the right side of his/her neck, his/her chin, and the right side of his/her forehead from his/her hairline just past his/her eyebrow and to his/her right cheek; no open areas were noted.
-The resident then was resting peacefully in his/her bed.
Record review of the resident's quarterly MDS dated [DATE] showed:
-He/she was cognitively impaired.
-He/she had absence of spoken words.
-He/she had behavioral symptoms.
-He/she required extensive two person assistance for bed mobility.
-He/she was totally dependent on two or more staff for transfer.
-He/she had non-verbal sounds of pain.
-He/she had not had falls since completion of the previous MDS (Note the resident had experienced falls).
Record review of the resident's quarterly MDS dated [DATE] showed:
-He/she was cognitively impaired.
-He/she had absence of spoken words.
-He/she had behavioral symptoms.
-He/she required extensive two person assistance for bed mobility.
-He/she was totally dependent on two or more staff for transfer.
-He/she had non-verbal sounds of pain.
-He/she had not had falls since completion of the previous MDS (Note the resident had experienced falls).
Record review of the resident's Physician's Orders Sheet (POS) dated 10/2020 showed his/her physician ordered:
-Ativan (antianxiety medication) 0.5 milligrams (mg), one tablet twice daily for anxiety/agitation/restlessness.
-Baclofen (muscle relaxer and an antispasmodic medication) 20 mg, one tablet four times daily for spasm of muscle.
-Levetiracetam (seizure medication) 100 mg twice daily for convulsions (seizures).
-Norco (opioid pain medication) 5-325 mg every eight hours for pain.
-Abilify (antipsychotic medication) 5 mg daily for mood disorder.
Observation of the resident on 10/20/20 at 9:14 A.M. showed:
-His/her room door was closed.
-Upon knocking, then opening his/her room door, he/she was observed lying on the mat on the floor next to his/her bed.
-He/she was alert, dressed and moving his/her head, right arm and right leg.
Observation of the resident on 10/20/20 at 11:29 A.M. showed:
-His/her room door was closed.
-Upon knocking, then opening his/her room door, he/she was observed lying on his/her room floor near his/her sink.
-His/her bed was in the lowest position and a mattress was on the floor next to his/her bed.
-He/she was alert and moving his/her head, right arm, and right leg.
During an interview on 10/21/20 at 10:36 A.M. the Administrator said:
-He/she was not aware that on 5/31/20 at 5:21 P.M. a licensed nurse heard the resident yelling out in a distressed manner and found him/her laying on his/her mattress next to his/her bed, face down with his/her head stuck between the mattress he/she was laying on and the frame of his/her bed and that the licensed nurse assessed the resident and noted that he/she had red markings on the right side of his/her neck, his/her chin, and the right side of his/her forehead from his/her hairline just past his/her eyebrow and to his/her right cheek.
-He/she was not aware of the incident.
-To her knowledge, no incident report was completed regarding the incident and no investigation of the incident was completed.
-He/she would expect an incident report when something like that occurred.
-The resident's care plan did not address a potential for injury related to the resident's bed/bed frame, the mattress next to the resident's bed, the resident moving to the floor from his/her bed.
-He/she would look to for any investigation and incident report that might have been completed.
During an interview on 12:13 P.M. LPN A said:
-On 5/31/20 he/she heard a noise, entered the resident's room and found the resident on the floor.
-The mattress on the floor was moved away from the resident's bed.
-The resident's head was stuck under his/her bed frame middle bar.
-He/she got a CNA to assist him/her, then he/she looked at the resident's head under his/her bedframe metal bar to see if it was safe to move the bed frame up.
-He/she then had the CNA move the bedframe up with the electronic control.
-He/she then assessed the resident.
-The resident was vocalizing in a distressed manner.
-He/she and the CNA transferred the resident to his/her bed using his/her sling.
-The resident continued to vocalize in a distressed manner for a half hour while he/she remained with the resident consoling him/her.
-He/she did not recall telling anyone regarding finding the resident's head stuck under his/her bed.
-He/she did not remember who was on duty or what day of the week this occurred; it was a long time ago.
-He/she would typically notify the Assistant Director of Nursing (ADON) or DON regarding resident incidents.
-In this resident case, he/she would not need to notify anyone of finding the resident on the floor or of this resident having his/her head under his/her bed frame because the resident did that on his/her own, it was a behavior.
-He/she found the resident on the floor several times each 12 hour shift he/she worked.
-He/she did not do anything other than transferring the resident back to his/her bed and checking the resident for injuries, bleeding, and if he/she needed to have incontinence care.
-The number of times he/she found on the floor during shifts he/she worked varied from four to six times.
During an interview on 10/22/20 at 12:58 P.M. CNA G said:
-He/she sometimes worked the resident's hall.
-He/she found the resident on his/her floor two to three times a shift.
-When he/she found the resident on his/her floor, he/she got another CNA and transferred the resident back to his/her bed and then told the nurse the resident was on his/her floor.
-It was in the resident's care plan that he/she rolled out of his/her bed and to put him/her back in his/her bed.
During an interview on 10/22/20 at 1:02 P.M. Nursing Assistant (NA) F said:
-He/she had found the resident on the floor with his/her head wedged under his/her bed and could not move him/her.
-This occurred in the past several months, he/she could not remember the date.
-He/she moved the resident's bed up with the bed control and freed his/her head.
-He/she then went and got a CNA and transferred the resident back to his/her bed.
-He/she then told the nurse the resident's was on the floor with his/her head wedged under his/her bed.
-Normally he/she found the resident on the floor about six to eight times during his/her eight hour shift.
-When he/she found the resident on the floor, he/she put him/her back in his/her bed; this was in his/her care plan; he/she would then tell the nurse.
-About three licensed nurses had told him/her to check on the resident frequently because he/she would get his/her head under his/her bed.
-He/she checked on the resident about every hour.
During an interview on 10/22/20 at 1:24 P.M. Registered Nurse (RN) A said:
-He/she had sometimes worked on the resident's hall and found him/her on the floor about two times a shift.
-The resident's bed was kept in the lowest position.
-He/she had found the resident with his/her head under his/her bed frame - his/her head was not wedged in the bed frame; his/her head was on the floor, under his/her bed frame, but not touching his/her bed frame.
-He/she was able to easily move the resident.
-On that occasion, he/she was not working on the resident's hall, a CNA had told her the resident was on the floor and he/she went to the resident's room.
-The resident was not injured, had no red marks and was not screaming.
-He/she told the charge nurse for the resident's hall, LPN A that the resident on had been on the floor.
During an interview on 10/22/20 at 2:16 P.M. Housekeeping Staff (HS) A said:
-He/she worked full time.
-He/she cleaned the resident's room once each day.
-He/she found the resident on his/her floor about two times weekly.
-He/she told a CNA or a licensed nurse when he/she found the resident on his/her floor.
During an interview on 10/22/20 at 2:16 P.M., the ADON said:
-He/she did not know much about the resident's history.
-Every five minutes the resident scooted out of his/her bed, it was his/her choice.
-The resident scooted on the floor, off the mat next to his/her bed and into rooms across the hall from his/her room.
-When staff find the resident on the floor they should see if he/she needed incontinence care.
-He/she had heard the resident at one time had squirmed under his/her bed; he/she did not recall that his/her head was stuck under his/her bed or that he/she had an injury, just that he/she was under his/her bed, that he/she had wiggled under his/her bed.
-He/she expected that when staff found the resident under his/her bed, they first get a licensed nurse to determine if the resident had any injuries, then figure out the best way to get her out from under his/her bed.
-He/she would not necessarily expect that if staff found the resident under his/her bed they would report that to management staff if he/she had no injuries; redness had to be reported to management.
-If the resident was stuck/wedged under his/her bed and then screamed for a half hour, that did not necessarily need to be reported to management staff.
-Staff were to notify management during regular working hours or call management after regular working hours if a resident fell, if a resident was sent out to a hospital, if facility staff had any questions; any resident injury of any kind needed to be reported to management staff; anything for which an incident report would be completed required notification to facility management staff.
-When the resident wiggled out of bed, that was not a fall because it was intentional, he/she had seen the resident intentionally wiggle out of his/her bed.
-He/she had never seen the resident roll out of bed; he/she would scoot to the edge of his/her bed and then push off, that was how he/she moved around his/her room.
-If the resident was stuck under his/her bed that would require an incident report.
-If the resident could not get out from under his/her bed by himself/herself, he/she would expect an incident report and for staff to notify management, if management was in the building, if management was not in the building, incident reports were slid under the DON's door.
-If a resident had a gross (very obvious) injury or had to be sent out to a hospital after hours, management was to be notified.
-Phone calls to physicians and family depended on the nature of what had occurred with the resident, typically after normal work hours if the resident had no injury, follow up phone calls would be made the next day.
-Management followed up on incidents, the following day if after normal working hours, by assessing the nature what occurred, if nursing notes were completed, if the doctor needed to be notified the physician is notified would be notified during this follow-up, if the resident had a gross injury, the doctor and family would be notified.
-He/she thought if he/she were involved in a discussion of the resident having his/her head under his/her bed, he/she would ask if there was anything the facility needed to do differently.
-Falls investigations are done with incident reports; part of the DON review is a review of the resident's care.
-In the time he/she had worked at the facility, there had been no changes to the resident's care to his/her knowledge.
-As long as there was any furniture, such as a bedside table in the resident's room, there was always the potential for the resident to get caught on those.
-He/she did not think anything different could be done to keep the resident safe.
During an interview on 10/22/20 at 1:52 P.M. the DON said:
-He/she was not aware the resident had his/her head under his/her bed frame and his/her bed had to be raised to move his/her head from his/her bed frame.
-He/she had wanted to remove the resident's bed frame but could not get agreement that it was an acceptable alternative.
-He/she wanted the resident's bed frame gone to keep the resident from hurting himself/herself, like for residents with Huntington disease (a progressive brain disorder that causes uncontrolled movements) who have just mats on their floor and walls.
-The resident moved around on his/her floor, he/she intentionally moved from his/her bed to his/her mat and off his/her mat; he/she moved around on his/her floor.
-When the resident moved from his/her bed to his/her mat and to his/her floor it was not treated like a fall.
-He/she had called someone at Department of Health and Senior Services (DHSS) Central Office, someone and Centers for Medicare and Medicaid Services (CMS), and a neurological center and was unsuccessful finding alternatives to the resident having a regular bed frame.
-There had been no changes to the resident's care in some time.
-He/she would like to get rid of the resident's bed frame because it may cause problems, the resident might be hurt; the resident could get his/her head stuck in his/her bed frame.
During an interview on 10/23/20 at 9:47 A.M. CNA G said:
-He/she had worked on the resident's hall a handful of times since May, 2020 and was familiar with him/her.
-When he/she worked on the resident's hall, he found the resident on his/her mat or on his/her floor a couple of times in his/her eight hour shift.
-To him/her this was the resident's way of saying something was wrong; his/her movement was him/her trying to get staff's attention.
-He/she did not think the resident could follow instructions from staff.
-He/she had never seen the resident with any of his/her body parts under his/her bed frame and he/she never heard the resident had been stuck under his/her bed or that his/her bed needed to be raised up to get him out from under his/her bed.
-When he/she transferred the resident back to his/her bed, he/she got help from another staff person, usually another CNA and used the soft sling to lift the resident.
-He/she had never seen the resident trying to move from one location to another location, he/she had only seen the resident having movement to get staff's attention.
-When he/she found the resident out of his/her bed, he/she told
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 observation, interview and record review, the facility failed to ensure one sampled resident (Resident #54) was afforde...
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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 one sampled resident (Resident #54) was afforded an opportunity to formulate advanced directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) out of 17 sampled residents. The facility census was 68 residents.
Record review of the facility Advance Directives and Refusal of Treatment policy date 10/1/10 showed:
-The resident has the right to refuse treatment and to formulate an advance directive for the management of his/her care.
-The resident will be given information and the opportunity to formulate Advance Directives, including but not limited to a Living Will and/or an attorney-in-fact appointed pursuant to a Durable Power of Attorney for Health Care.
-The resident shall have a copy of his/her Advance Directive(s), if any, made a part of his/her medical record.
-Prior to or upon admission, the facility Social Services staff will provide the resident or family with information about Advance Directives, Do-Not Resuscitate (DNR - Do not perform chest compression or rescue breathing in the resident stops breathing or heartbeat stops), (WD) and Withhold (WH) orders, policies, forms and completion procedures.
-The resident's Advanced Directives, DNR, WD/WH, status should be reviewed with all readmissions; Social Services should enter an admission note in the resident's record regarding the update.
-In cases when the parties involved cannot reach a decision as to the need or implementation of DNR and WD/WH orders and the facility is unable to resolve the situation, the matter should be referred to the Ethics Committee.
-Facility Social Services shall assist the resident or family in ensuring that they are aware of their options regarding Advance Directives.
-Throughout the resident's time at the facility, all discussions leading to the consideration of DNR or WD/WH orders should be documented by Social Services and nursing staff.
-DNR. WD/WH should be reviewed by the Interdisciplinary Care Plan Team during the quarterly update.
1. Record review of Resident #54's Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's care plan dated 6/9/20 showed no mention of advanced directives.
Record review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/12/20 showed:
-He/she had clear speech.
-He/she understood others and was understood others.
-He/she was moderately cognitively impaired.
Record review of the resident's Physician's Orders Sheet showed he/she had the following diagnoses:
-Tracheostomy (a surgically made hole that goes through the front of your neck into your trachea, or windpipe; a breathing tube, called a trach tube, is placed through the hole and directly into your windpipe to help you breathe) status.
-Malignant neoplasm (cancerous tumor) of the tongue and secondary malignant neoplasm of the brain.
Record review of the resident's electronic medical record (EMR) and his/her paper chart on 10/21/20 showed no record that he/she was afforded an opportunity to formulate advanced directives.
Observation and interview with the resident on 10/21/20 at 11:46 A.M. showed:
-He/she was alert and seated in a chair in his/her room.
-He/she did not speak.
-He/she nodded yes and no and gestured with his/her hands.
-When asked if he/she wanted any advanced directives, he/she waved his/her hand and grimaced.
Record review of the resident's Social Services Progress Note dated 10/21/20 showed:
-Social Services spoke with the resident's sibling that morning regarding whether he/she had Designated Power of Attorney or Advanced Directives paper work for the resident.
-The resident's sibling said that every time he/she asked the resident regarding DPOA or Advanced Directives, the resident did not want to complete DPOA or Advanced Directives papers.
-The resident's sibling asked that the facility try to talk to the resident about doing DPOA paperwork.
During an interview on 10/27/20 at 11:24 A.M. the Social Services staff said:
-He/she had not discussed DPOA or Advanced Directives with the resident.
-This was on his/her list of things to do.
During an interview on 10/26/20 at 1:08 P.M. the MDS/Care Plan Coordinator said:
-He/she conducted quarterly care plan reviews.
-Advanced directives should be reviewed at each care plan review if the resident's advanced directives were not previously made clear.
-If a resident had formulated advanced directives, it was addressed in their care plan.
-Social Services checks advanced directives and code status for residents.
-He/she, the Director of Nursing (DON) and Social Services make sure the facility has the proper paper work for advanced directives and he/she puts the residents advanced directive in the resident's care plan.
-The licensed nurses could also review residents' advanced directives, or medical records staff or the Administrator.
-He/she did not recall discussing and had not documented that the resident's care plan review included a review of and opportunity for the resident to formulate advanced directives.
During an interview on 10/27/20 at 12:40 P.M. the Director of Nursing (DON) and corporate Regional Nurse said:
-Each resident should periodically have an opportunity to formulate advanced directives.
-Advanced directives, including DNR required a physician's order and should be addressed on residents' care plans.
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 a resident being discharged from the facility to the hospita...
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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 a resident being discharged from the facility to the hospital received a discharge notification for one sampled resident (Resident #31) out of 17 sampled residents. The facility census was 68 residents.
1. Record review of Resident #31's Face Sheet showed he/she was admitted to the facility on [DATE] and was readmitted on [DATE].
Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/21/20 showed he/she:
-Was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
-Required extensive staff assistance for dressing and bathing.
-Required total staff assistance for toileting.
Record review of the resident's electronic medical record showed:
-He/She was sent to the hospital for abdominal pain and not having a bowel movement for several days despite treatment on 10/15/20.
--No documentation a discharge notice was given to the resident.
-He/She was readmitted to the facility on [DATE].
During an interview on 10/19/20 at 11:13 A.M., the resident said:
-He/She had been transferred to the hospital earlier that month.
-He/She had just returned to the facility the previous day.
-He/She did not receive a discharge notice from the facility when he/she was sent to the hospital.
During an interview on 10/26/20 at 12:33 P.M., the administrator said he/she could not find a discharge notification for the resident's discharge from the facility on 10/15/20.
During an interview on 10/27/20 at 9:47 A.M., Licensed Practical Nurse (LPN) A said:
-The nurse on duty at the time the resident is discharged from the facility was responsible to ensure the resident received his/her discharge notification.
-Staff should make a copy of the discharge notice and give it to the billing department.
-He/She could not find a discharge notification on the resident's chart.
During an interview on 10/27/20 at 1:12 P.M., the Director of Nursing (DON) said:
-He/She expected the nurse on duty to provide the resident with a discharge notice when the resident is discharged from the facility.
-That would include when the resident was being discharged to the hospital.
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 ensure a resident being discharged from the facility to the hospita...
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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 a resident being discharged from the facility to the hospital received a bed hold notice for one sampled resident (Resident #31) out of 17 sampled residents. The facility census was 68 residents,
1. Record review of Resident #31's Face Sheet showed he/she was admitted to the facility on [DATE] and was readmitted on [DATE].
Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/21/20 showed he/she:
-Was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
-Required extensive staff assistance for dressing and bathing.
-Required total staff assistance for toileting.
Record review of the resident's electronic medical record showed:
-He/She was sent to the hospital for abdominal pain and not having a bowel movement for several days despite treatment on 10/15/20.
--No documentation a bed hold notice was given to the resident.
-He/She was readmitted to the facility on [DATE].
During an interview on 10/19/20 at 11:13 A.M., the resident said:
-He/She had been transferred to the hospital earlier that month.
-He/She had just returned to the facility the previous day.
-He/She did not receive a bed hold notice from the facility when he/she was sent to the hospital.
During an interview on 10/26/20 at 12:33 P.M., the administrator said he/she could not find a bed hold notice for the resident's discharge from the facility on 10/15/20.
During an interview on 10/27/20 at 9:47 A.M., Licensed Practical Nurse (LPN) A said:
-The nurse on duty at the time the resident is discharged from the facility was responsible to ensure the resident received his/her bed hold notice.
-Staff should make a copy of the bed hold notice and give it to the billing department.
-He/She could not find a bed hold notice on the resident's chart.
During an interview on 10/27/20 at 1:12 P.M., the Director of Nursing (DON) said:
-He/She expected the nurse on duty to provide the resident with a bed hold notice when the resident is discharged from the facility.
-That would include when the resident was being discharged to the hospital.
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 ensure a base line care plan was developed and reviewed with the re...
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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 a base line care plan was developed and reviewed with the resident or the resident's responsible party, and to provide a copy of the base line care plan to the resident/responsible party within 48 hours of the resident's admission to the facility for two sampled residents (Resident's #13 and #62) out of 17 sampled residents. The facility census was 68 residents.
Record review of the facility Person Centered Care Plan policy dated 7/17/18 showed:
-Person centered plans of care are developed by the interdisciplinary team to coordinate and communicate care approaches and goals of the resident consistent with the residents rights.
-The facility develops and implements a baseline plan of care within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident.
-The baseline plan of care should be initiated by the Minimum Data Set (MDS - a federally mandated assessment tool required to be completed for care planning) Coordinator/Designee based on referral information dietary observation, resident and/or resident representative and staff input within 48 hours of admission.
-The baseline care plan summary is provided to the resident/resident representative by the MDS Coordinator after the baseline care plan is established and prior to completion of the resident's comprehensive care plan.
Record review of facility's policy dated July 17, 2018 policy titled Person Centered Care Plans:
-According to federal regulations, the facility will develop and implement a baseline plan of care within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident.
-Baseline Plan of Care should be initiated by the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) coordinator/designee based on referral information, dietary observation, resident/guest/or resident representative and staff input within 48 hours of admission.
-Baseline care plan summary would be provided to resident/resident representative by MDS coordinator, after baseline care plan established, and prior to completion of comprehensive are plan.
1. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) without behaviors.
-Long term use of insulin.
-Hypertension (high blood pressure).
-Paroxysmal atrial fibrillation (abnormal heart rhythm).
-Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Muscle weakness (generalized).
-Difficulty in walking.
-Cognitive communication deficit.
-His/her primary language was Korean.
Record review of the resident's medical record dated 4/13/20 - 10/26/20 showed:
-No documentation by the facility staff of an initial 48 hour care plan.
-No documentation by the facility staff an initial 48 hour care plan was reviewed with the resident or the resident's responsible party.
2. Record review of Resident #62's Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:
-Cellulitis (an infection of deep skin tissue).
-Zoster with other complications (shingles - A reactivation of the chickenpox virus in the body, causing a painful rash that may appear as a stripe of blisters on the trunk of the body. Pain can persist even after the rash is gone).
-Methicillin Resistant Staphylococcus Aureus (MRSA - a type of bacteria that is resistant to many antibiotics).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behavioral disturbance.
Record review of the resident's electronic medical record and paper medical record showed no documentation an initial baseline care plan was developed, reviewed, or a copy provided to the resident or the resident's responsible party.
3. During an interview on 10/26/20 at 9:58 A. M., the MDS coordinator said:
-The initial care plan was done as a comprehensive care plan.
-The 48 hour initial care plan was given to the residents and the residents' family before the COVID (a new disease caused by a novel (new) coronavirus) lockdown, but since lock down they are not being done.
-The facility was just doing the comprehensive care plan.
During an interview on 10/27/20 at 1:40 P.M., the Director of Nursing (DON) said:
-Baseline care plan was supposed to be given to the resident and responsible party.
-This should be done within 48 hours of the resident's admission to the facility.
-The nurse, MDS coordinator, Social Service Designee should have provided a copy of the baseline care plan summary to the resident or residents representative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2 .Record review of Resident 63's Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2 .Record review of Resident 63's Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's Care Plan dated 10/23/19 and updated on 9/12/20 showed:
-He/she was at risk for falls.
-Staff were to encourage clutter free environment and path to bathroom.
-Staff were to assist with ambulation, toileting and mobility as needed.
--NOTE: the resident's care plan was not updated after the resident's actual fall with a fracture on 9/6/20. The resident was readmitted to the facility with a splint/brace on his/her right arm.
-Record review of the resident's Nurse Notes dated 9/6/20 showed:
-The resident fell while walking down the 400 Hall toward the nurse's desk.
-The Certified Medical Technician (CMT) saw the resident fall.
-The CMT reported the resident hit his/her head on the wall and his/her elbow on the floor.
-The resident reported he/she was not hurt at that time.
-Staff assisted the resident to his /her feet and walked him/her to his/ her bed.
-The nurse noticed the resident's right elbow was out of shape and started to swell.
-He/she notified the residents physician and obtained orders to send the resident to the hospital.
-The resident's family was also notified.
Record review of the resident's Nursing admission Review dated 9/8/20 showed:
-The resident was readmitted to the facility after a hospital stay.
-The resident fractured his/her right elbow from a fall on 9/6/20.
-The resident had a splint.
Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/16/20 showed he/she:
-Was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15.
-Was independent with transfers, toileting, personal hygiene, walking and eating.
-Resident required staff supervision with dressing.
-Required extensive staff assistance with bathing.
-Had limited Range of Motion (ROM) with impaired mobility in his/her upper extremities on one side.
-Used a walker and wheelchair.
-He/She had no falls since admitted .
Observation on 10/19/20 at 10:10 A.M. of the resident showed:
-The resident was self-propelling in the hall in his/her wheelchair.
-He/She had a brace on his/her right arm.
During an interview on 10/20/20 at 12:57 P.M., the resident said:
-He/She fell at the facility and broke his/her right arm.
-He/She lost his/her balance when he/she fell.
-He/She had an immobilizer/brace on his/her right arm.
During an interview on 10/22/20 at 12:25 P.M., the resident said:
-He/She fell in his/her room.
-He/She was wearing house shoes the day he/she fell.
3. During an interview on 10/23/20 at 11:15 A.M., Licensed Practical Nurse (LPN) A said:
-That updates to the resident's Care Plan could be found in the resident's chart.
-The people involved in the updating of the resident's chart would be the Resident, the Social Worker (SW), the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the-Durable Power of Attorney (DPOA) and sometimes the MDS Coordinator.
During an interview on 10/27/20 at 1:40 P.M the DON said:
-Care plans should be updated to reflect the resident's current condition,
-Care plans should be individualized to the resident.
Based on observation, interview and record review, the facility failed to revise a resident's care plan to reflect the resident's current condition to include the resident's Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) code status for one sampled resident (Resident #29), and after one resident's fall with a fracture for one sampled resident (Resident #63), out of 17 sampled residents. The facility census was 68 residents.
Record review of the facility Person Centered Care Plan policy dated 7/17/18 showed:
-Person centered plans of care are developed by the interdisciplinary team to coordinate and communicate care approaches and goals of the resident consistent with the residents rights.
-The facility develops a comprehensive person centered plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the resident's comprehensive assessment and based on the resident's goals and preferences.
-The comprehensive plan of care is completed within seven days of the resident's admission Resident Assessment Instrument (RAI - the federally mandated assessment process that helps nursing home staff gather definitive information on a resident's strengths and needs which must be addressed in the individualized care plan).
-The comprehensive plan of care should be reviewed quarterly and with a significant change in a resident's condition.
1. Record review of Resident #29's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] and was receiving hospice services (end of life care).
Record review of the resident's paper medical record showed a signed DNR form on the front of the resident's chart.
Record review of the resident's Care Plan dated 2/27/19 showed no documentation of the resident's code status.
Record review of the resident's October 2020 Physician's Order Sheet (POS) showed the resident had a DNR code status.
During an interview on 10/27/20 at 9:18 A.M., Certified Nursing Assistant (CNA) E said:
-He/She would know a resident's code status by looking at his/her chart.
-The resident's code status should be on a care plan.
During an interview on 10/27/20 at 9:46 A.M., Licensed Practical Nurse (LPN) A said:
-The resident had a DNR form on his/her paper chart.
-The resident had a physician's order for DNR code status.
-The resident's code status should be on his/her care plan.
During an interview on 10/27/20 at 1:17 P.M., the Director of Nursing (DON) said:
-Staff can verify a resident's code status by looking at his/her paper chart.
-If the resident had a DNR order it would be on the resident's POS.
-If there were no code status orders on the resident's POS, then it was assumed the resident had a Full Code status.
-The resident's code status should be on his/her care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
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 develop a discharge plan according to residents needs for one samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review , the facility failed to develop a discharge plan according to residents needs for one sampled closed record (Resident # 72) out of 17 sampled residents and three closed records. Facility census was 68 residents.
Record review of the facility's Discharge Summary and Plan of Care policy dated November 28 2016 showed:
-Appropriate discharge planning and communication of necessary information to the continuing care provider, after discharge of a resident from the facility, help the new care provider understand the resident goal and needs.
-A post discharge plan of care developed with the resident and his/her family, to assist the resident to adjust to his/her new living environment.
-The planned discharge review should be initiated upon determination that the resident planned to discharge and should be updated on-going, to be completed before the resident's discharge.
-Discharge to home instructions should be completed prior to the resident's discharge, preferably on the date of discharge.
1. Record review of Resident #72's Face Sheet showed he/she was admitted to the facility on [DATE] and discharged on 7/28/20 with the following diagnoses:
-Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system).
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).
-Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Dependent on supplemental oxygen.
-Tracheostomy (surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions).
-Gastrostomy (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube).
Record review of the resident's Speech Therapy (ST) notes showed:
-On 6/26/20 a plan of care was developed and skilled interventions recommended for improving and completion of higher level functional tasks to improve transition from skilled nursing facility to home.
-On 6/28/20 a plan of care was developed and skilled interventions recommended for improving and completion of higher level functional tasks to improve transition from skilled nursing facility to home.
Record review of the residents Social Service notes dated 6/30/20 showed he/she was admitted to the facility on [DATE] for skilled services with a plan to discharge home.
Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 7/1/20 showed he/she:
-Was moderately cognitively impaired with a BIMs (brief interview for mental status) of 11 out of 15.
-Required extensive staff assistance with bed mobility, dressing, toileting, hygiene, and bathing.
-Required total staff assistance with transfers and locomotion.
-Required supervision of staff with eating.
-Utilized a walker or wheelchair.
-Required supplemental oxygen.
-Received Speech Therapy, Occupational Therapy, and Physical Therapy.
-The resident's overall goal established during the assessment was left blank, including if the resident expected to discharge to the community or if the resident expected to discharge to another facility.
-The resident had no active discharge plan to return to the community.
Record review of the resident's electronic medical record showed:
-No documentation the facility involved the resident in developing a discharge plan that reflected the resident's goals, needs, and treatment preferences in conjunction with the resident's support system.
-No documentation the resident received information about possible discharge to the community.
-No documentation the facility assisted the resident find alternate placement at another long-term care facility.
-No documentation the facility assisted the resident find a home health provider.
-No documentation the facility completed a recapitulations of stay.
-No documentation by the facility staff related to the resident's discharge.
Record review of the resident's Social Service notes dated 7/24/20 showed he/she would be discharged on 7/28/20 and Social Service would set up home health.
Record review of the resident's Occupational Therapy notes dated 7/27/20 showed he/she had knowledge of exercises and did not require handouts once home.
Record record review of the resident's Discharge to Home Instructions dated 7/28/20 showed:
-No exercise/mobility instruction.
-Symptoms to report after discharge.
-Contact number for non-emergency instructions.
-No home health needs.
-No documentation where he/she went after discharge from the facility.
-No recapitulation of his/her stay at the facility.
During an interview on 10/26/20 1:15 P.M., Licensed Practical Nurse (LPN) A said:
-Social Service Designee would inform the nurse who was to be discharged .
-The nurse would complete the discharge paperwork.
-He/she was not a part of the resident discharge planning prior to the resident being discharged .
-He/she would go over the discharge paperwork with the resident.
During and interview on 10/27/20 1:40 P.M., Director of Nursing (DON) said:
-In discharge planning the Interdisciplinary Team (IDT) would discuss the residents plan for discharge.
-He/she should have a planned discharge assessment in the electronic health record.
-Each area of the planned discharge assessment should be completed for each discipline.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
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 complete a comprehensive discharge summary which included a recapit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive discharge summary which included a recapitulation of stay for one sampled closed record (Resident #72) out of 17 sampled residents and three closed records. The facility census was 68 residents.
Record review of facility's Discharge Summary and Plan of Care policy dated November 28, 2016 showed:
-If the facility anticipated the discharge of a resident, a discharge plan summary should be developed.
-Upon discharge of a resident, a discharge summary is provided.
-The discharge summary should include a recapitulation of residents stay, a final summary of the residents status at time of discharge, a post discharge plan of care developed with the resident and his/her family to assist the resident to adjust to his/her new living environment,and a reconciliation of pre and post discharge medications.
-Planned discharge review should be imitated upon determination that the resident planned to discharge and should be updated on-going, and be completed before discharge.
-Discharge to home instructions should be completed prior to discharge, preferably on the date of discharge.
1. Record review of Resident #72 Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of Departmental Notes for the resident showed:
-Therapy note dated 6/26/2020 showed the plan of care was developed and skilled intervention recommended for improved completion of higher level functional tasks to improve transition from skilled nursing facility to home.
-Therapy note dated 6/28/2020 showed the plan of care was developed and skilled intervention recommended for improved completion of higher level functional tasks to improve transition from skilled nursing facility to home.
-Social Services note dated 6/30/2020 showed he/she was admitted to the facility for skilled services and his/her plan was to discharge home
Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 7/1/20 showed he/she:
-Was moderately cognitively impaired.
-He/she had a BIMs (brief interview for mental status) of 11 out of 15.
-Required extensive staff assistance with bed mobility, toileting, hygiene, and bathing.
-Required total staff assistance with transfers and locomotion.
-Required staff supervision with eating.
-Required a walker or wheelchair.
-The resident's overall goal established during the assessment was left blank, including if the resident expected to discharge to the community or if the resident expected to discharge to another facility.
-The resident had no active discharge plan to return to the community.
Record review of Departmental Notes for the resident showed:
-Social Services note dated 7/24/2020 showed his/her last covered day would be Monday 7/27/2020 with discharge on [DATE], and he/she would set up home health.
-Therapy note dated 7/27/2020 showed the resident did not require any therapy handouts to use once home.
Record review of the resident's Discharge to Home Instructions dated 7/28/2020 showed:
- No documentation of where he/she went upon discharge.
-There was no documentation of a recapitulation of the resident's stay.
-There was no documentation for follow up appointments after discharge.
-There was no documentation of exercise/mobility care instructions/restrictions.
-There was no documentation on symptoms to report to the resident's physician after discharge.
-There was no documentation on who to contact for non emergency questions.
During an interview on 10/26/2020 at 1:15 P.M. Licensed Practical Nurse (LPN) A said:
-He/She was unsure if there was an interdisciplinary team.
-Social Service Designee tells him/her who was to be discharged .
-He/she then filled out the Discharge to Home form.
-He/she then would go over the form with the resident.
During an interview on 10/27/20 at 1:40 P.M., the Director of Nursing (DON) said:
-There should be a discharge assessment in the Electronic Medical Record (EMR).
-Each area of the assessment should be complete for each discipline.
-The assessment should include details of where he/she went to, and that he/she was able to take care of his/her needs.
-The recapitulation should be in the assessment.
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 observation, interview and record review, the facility failed to provide meaningful activities to meet the interests of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide meaningful activities to meet the interests of and support the physical, mental, and psychosocial well-being of two sampled residents (Resident #48 and #64) out of 17 sampled residents. The facility census was 68 residents.
Record review of the facility Activity Program Management policy updated 3/1/2008 showed:
-The purpose of the policy was to help activity staff understand aging complications experienced by the elderly, and the federal and state requirements affecting long term care practice.
-The quality of care section of the activity program manual was dedicated and a resource to the activity program staff regarding program management related to medical and nursing care needs of the residents.
-No other parts of the activity program manual were provided by the facility.
1. Record review of the facility's activity calendar dated 10/2020 showed:
-10/19/20: Daily handouts, riddles, 100 hall cupcakes, and door decorating.
-10/20/20: Daily handouts, trivia, 200 hall cupcakes, door decorating.
-10/21/20: Daily handouts, 300 hall cupcakes, bingo, and local shopping.
-10/22/20: Daily handouts, puzzles, 400 hall cupcakes, and door decorating.
-10/23/20: Evening/weekend handouts, 500 hall cupcakes, and door decorating.
-10/26/20: Daily handouts, word search, and crafts.
-10/27/20: Daily handouts, wacky wordies, and crafts.
Record review of the evening and weekend edition of the facilities Daily Chronicle dated 10/23/20, 10/24/20 and 10/25/20 showed:
-On this date and birthday events.
-Trivia questions.
-Owl poetry.
-Word games and mazes.
-Crossword puzzles.
-Word searches.
-Coloring.
2. Record review of Resident #48's Face Sheet dated 9/3/20 showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Cerebrovascular Accident (CVA, stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke).
-Aphasia (loss of ability to produce or comprehend language due to brain injury).
-Mixed receptive expressive language disorder (a communication disorder in which both the receptive and expressive areas of communication may be affected in any degree, from mild to severe. The person has difficulty understanding words and sentences).
-Hemiplegia/hemiparesis (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain).
-Was under [AGE] years old.
-Had a court appointed Legal Guardian (a person who has the legal authority to care for the personal and property interests of another person).
Record review of the resident's Room Activity Participation Record (due to pandemic room activities only) dated 9/3/20 through 9/30/20 showed:
-The resident participated in the following activities.
--Religious activities on television four times.
--Hall bingo was completed twelve times.
--Handouts were given twenty one times.
--Diversional activities were completed four times.
--There were no documented one on one activities for the resident.
Record review of the resident's activities care plan dated 9/7/20 showed:
-The resident chose daily activities as computer games and the staff needed to make sure his/her computer was charged.
-Did not have staff documentation that showed the resident's choices of meaningful activities.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by the facility staff for care planning) dated 9/10/20 showed he/she:
-Was unable to be interviewed to determine his/her cognition.
-Had limited range of motion on the upper and lower extremities on one side of his/her body.
-Thought it was somewhat important to be able to have books, magazines, and music as activities.
-Thought it was not important to have religious services.
-Thought it was very important to have access to pets, groups of people, go outside, and do his/her favorite activities.
Record review of the resident's Room Activity Participation Record (due to pandemic room activities only) dated 10/1/20 through 10/21/20 showed:
-The resident participated in the following activities.
--Handouts were given five times.
--Religious activities on television four times.
--Diversional activities were completed five times.
--Two visits were made to the resident's room.
--Hall bingo was done two times.
Observation on 10/19/20 at 11:20 A.M. showed the resident:
-Was in his/her room in his/her wheel chair.
-Had limited range of motion on the right upper and lower extremity of his/her body.
-Did respond yes or no to some questions but not able to answer most questions.
Observation on 10/20/29 at 11:41 A.M. showed:
-The resident was in his/her room with headphones on his/her head watching a show on his/her laptop.
-There were no activities being conducted on the unit.
Record review of the resident's electronic medical record on 10/20/20 showed no activity assessments.
During a telephone interview on 10/20/20 at 2:55 P.M., the resident's Legal Guardian said:
-He/she came to see the resident every other day.
-The resident was lonely at times because of not having things to do.
-He/she was not aware the resident had any one on one activities being done with him/her by the staff.
-He/she had brought the resident a lap top to use.
-He/she wished the staff would do more crafts with the resident.
Observation on 10/22/20 at 11:15 A.M. showed:
-The resident was in his/her wheelchair by the nurses' station.
-There were no activities being conducted on the unit.
Observation on 10/22/20 at 12:07 P.M. showed the resident in his/her room seated in his/her wheelchair watching a show on his/her lap top while eating lunch.
During an interview on 10/23/20 at 10:52 A.M. the Social Services Designee (SSD) said:
-The Activity Director was taking residents out two at a time and painting outside.
-The resident liked to listen to music and liked to visit with people.
During an interview on 10/23/20 at 11:52 A.M. the Activity Director said:
-He/she did not complete one on one activities with the resident.
-He/she would talk to the resident when he/she saw him/her in the hall.
-He/she did participate in hall bingo.
-He/she did not do any arts and crafts with the resident.
-He/she did take the resident outside but did not stay with him/her.
-The resident could not cognitively do the Daily Chronicle activity packet handout.
-The resident was more independent with activities.
Observation on 10/26/20 at 2:34 P.M. showed:
-The resident was in his/her wheelchair by the nurses' station.
-There were no activities being conducted on the unit.
Observation on 10/27/20 at 9:36 A.M. showed:
-The resident was in his/her room in the bathroom.
-There were no activities being conducted on the unit.
During an interview on 10/27/20 at 10:08 A.M., Licensed Practical Nurse (LPN) A said he/she thought the resident could do crossword puzzles but was unsure if he/she could read.
3. Record review of Resident #64's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Major depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Stroke.
Record review of the resident's Activities care plan updated 3/4/20 showed he/she:
-Was able to participate in bingo and noodle wars.
-Preferred to have morning activities.
-Needed the assistance of staff for activities.
-Did not have staff documentation that showed the residents choices of meaningful activities.
Record review of the resident's Room Activity Participation Record (due to pandemic room activities only) dated 8/1/20 through 8/31/20 showed:
-The resident participated in the following activities.
--Handouts were given one time.
--Religious activities on television four times.
--Diversional activities were completed four times.
--Outside time was completed three times.
--Hall bingo was done twelve times.
Record review of the resident's Room Activity Participation Record (due to pandemic room activities only) dated 9/1/20 through 9/30/20 showed:
-The resident participated in the following activities.
--Handouts were not given to the resident.
--Religious activities on television four times.
--Diversional activities were completed four times.
--Hall bingo was done five times.
--Outside time was completed five times.
Record review of the resident's annual MDS dated [DATE] showed he/she:
-Was cognitively intact.
-Was totally dependent on staff for transfers.
-Thought it was somewhat important to be around pets or groups of people.
-Thought it was not important to have books, magazines, or newspapers to read.
-Thought it was very important to have music, news, religions services, go outside, and do his/her favorite activities.
Record review of the resident's Room Activity Participation Record (due to pandemic room activities only) dated 10/1/20 through 10/21/20 showed:
-The resident participated in the following activities.
--Handouts were not given to the resident.
--Religious activities on television three times.
--Diversional activities were not completed.
--Hall bingo was done one times.
--Outside time was not done.
During an interview on 10/19/20 at 11:07 P.M. the resident said:
-He/she had not had any room visits from the activity department.
-Bingo used to be done twice a week and this activity was no longer being done.
-Bingo was his/her favorite activity.
-Bingo was done only one time this month.
Record review of the resident's electronic medical record on 10/20/20 showed no activity assessments.
Observation on 10/22/20 at 9:21 A.M. showed the resident was lying in bed in his/her room.
Observation on 10/22/20 at 12:11 P.M. showed the resident was in his/her wheelchair in his/her room watching television and eating lunch.
Observation on 10/23/20 at 10:37 A.M. showed the resident was lying in bed watching television.
Observation on 10/27/20 at 9:36 A.M. showed:
-The resident was in his/her room lying in bed.
-There were no activities being conducted on the unit.
During an interview on 10/23/20 at 11:52 A.M. the Activity Director said:
-He/she would visit with the resident at times.
-The resident liked bingo and western movies.
4. During an interview on 10/23/20 at 11:52 A.M. the Activity Director said:
-He/she was the only staff member assisting the residents with activities.
-There were no other activity staff.
-He/she was responsible for completing the residents' activity assessments annually and quarterly.
-He/she had not been able to complete the activity assessments because he/she also worked on the floor as a Certified Medication Technician (CMT).
-He/she would try to do activity related tasks about 30 hours per week.
-He/she spent about ten hours per week working on the floor assisting residents.
-He/she would help answer resident call lights also.
-He/she did not conduct any activities this morning because he/she was busy making Daily Chronicle packets.
-He/she had not been passing out cupcakes this week.
-The facility management did not like him/her buying cupcakes and he/she only had a small cookie oven to bake in.
-He/she could not make the cupcakes with the small cookie oven.
-He/she had made cookies at the beginning of the week and passed them out on a hall and this was considered a one on one activity.
-He/she was going door to door and decorating the residents' room doors.
-He/she did hall bingo with the residents weekly but did not do this activity this week.
-Many of the residents did not like bingo.
During an interview on 10/23/20 at 12:25 P.M. Certified Nurses Assistant (CNA) D said:
-He/she had not seen any activities being done with the residents on the hall.
-He/she had not seen any one on one activities being done with the residents.
-Sometimes, he/she would take a resident outside.
During an interview on 10/26/20 at 2:36 P.M., the Director of Nursing (DON) said he/she had not seen any activity programs being done for the residents this afternoon.
During an interview on 10/27/20 at 9:38 A.M., LPN B said:
-He/she had not seen on going activities being completed on the halls for the residents recently.
-Sometimes, hall bingo was done with the residents.
-He/she saw the Activity Director paint outside with two residents.
-He/she saw the Activity Director paint a resident's nails yesterday.
-He/she had not seen on-going activities, maybe hallway bingo.
During an interview on 10/27/20 at 10:08 A.M., LPN A said:
-The Activity Director did get pulled to work on the floor instead of completing activities.
-The Activity Director worked the evening shift as a CMT quite often since July 2020 and would also work on the weekends.
-Activities were not being completed for the residents.
-He/she could not remember the last time hall bingo was done.
-There was only one activity person on staff.
During an interview on 10/27/20 at 12:16 P.M. the Assistant Director of Nursing (ADON), the DON, and the Regional Nurse Consultant (previously the interim DON) said:
-DON:
--He/she was unsure how much time the Activity Director spent working on the floor as a CMT versus completing activities for the residents.
-Regional Nurse Consultant:
--There was one activity staff member for the building.
--Activity assessments should be completed by the Activity Director on admission and a quarterly basis.
--The assessment should be specific to what the resident's interest were.
--All residents should have the opportunity to participate in daily activities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #62's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #62's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Cellulitis (an infection of deep skin tissue).
-Zoster with other complications (shingles - A reactivation of the chickenpox virus in the body, causing a painful rash that may appear as a stripe of blisters on the trunk of the body. Pain can persist even after the rash is gone).
-Methicillin Resistant Staphylococcus Aureus (MRSA - a type of bacteria that is resistant to many antibiotics).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behavioral disturbance.
Record review of the resident's Hospital to Long-Term Care Handoff Nursing Communication forms dated 10/3/20 showed:
-The resident had a non-intact skin area that was a procedure site.
-A body diagram had procedure site was circled at the lower back region.
-The resident had a recent infection of shingles.
Record review of the resident's Physician's Order Sheet (POS) dated October 2020 showed:
-Observe midline lower back dressing every shift, change as needed for soiling/dislodging dated 10/4/20.
-Observe left lateral lower back dressing every shift, change as needed for soiling/dislodging dated 10/4/20.
-Negative Pressure Wound Treatment (Wound Vacuum Assisted Closure - Wound V.A.C. - negative pressure wound therapy, a type of therapy to help wound healing by decreasing air pressure around the wound with a vacuum pump which pulls fluid and infection from a wound) to be applied to the resident's left lower back set at 125 millimeters (mm). Dressing changed every Monday, Wednesday, and Friday as needed. Check every shift. Dated 10/20/20.
-Negative Pressure Wound Treatment to be applied to the resident's left lateral back set at 125 mm. Dressing changed every Monday, Wednesday, and Friday as needed. Check every shift. Dated 10/20/20.
-Negative Pressure Wound Treatment to be applied to the resident's left lower back set at 125 mm. Dressing changed every Monday, Wednesday, and Friday scheduled during the day shift. Check every shift. Dated 10/23/20.
-Negative Pressure Wound Treatment to be applied to the resident's left lateral back set at 125 mm. Dressing changed every Monday, Wednesday, and Friday scheduled during the day shift. Check every shift. Dated 10/23/20.
Record review of the resident's Medication Administration Record (MAR) dated October 2020 showed:
-Skin Audit to be done weekly, record 0 for no new skin problems and 1 for new skin problems, follow up in notes dated 10/3/20.
-Two skin assessments were checked as being completed.
-On 10/10/20 staff documented 0 - no, indicating the resident did not have a new skin problem.
-On 10/17/20 staff documented 0 - no, indicating the resident did not have a new skin problem.
Record review of the resident's Treatment Administration Record (TAR) dated October 2020 showed:
-Midline lower back dressing, cleanse area with wound cleaner, apply Mepilex dressing (a wound dressing) as needed for soilage/dislodging dated 10/4/20 and discontinued on 10/7/20. No documentation the treatment was completed on 10/4/20 and 10/7/20.
-Left lateral lower back dressing, cleanse area with wound cleaner, apply moist gauze to wound bed and cover with Mepilex dressing as needed for soilage/dislodging dated 10/4/20 and discontinued on 10/7/20. No documentation the treatment was completed on 10/4/20 and 10/7/20.
-Midline lower back dressing, cleanse area with wound cleanser apply moistened 4x4s (a gauze dressing) to wound bed. Spray periwound (the skin surrounding the wound) with non-sting barrier. Protect with abdominal (ABD) thick wound dressing. Adhere with Medipore tape. Treat daily and as needed (PRN). May treat with other wound dated 10/7/20 and discontinued on 10/14/20.
--No documentation the treatment was completed on 10/7/20, 10/8/20, 10/9/20, 10/11/20, 10/12/20, and 10/13/20.
-Left lateral back dressing, cleanse area with wound cleanser apply moistened 4x4s to wound bed. Spray periwound with non-sting barrier. Protect with ABD thick wound dressing. Adhere with Medipore tape. Treat daily and PRN. May treat with other wound dated 10/7/20 and discontinued on 10/14/20.
--No documentation the treatment was completed on 10/7/20, 10/8/20, 10/9/20, 10/11/20, 10/12/20, and 10/13/20.
-Midline lower back dressing, cleanse area with wound cleanser apply collagen (Collagen provides the matrix for the body's tissue structure, used for wounds that have stalled in healing - chronic wounds; Characteristics include promotion of new tissue growth, wound debridement, and pulls wound edges together) to wound bed. Spray periwound with non-sting barrier. Protect with ABD thick wound dressing. Adhere with Medipore tape. Treat daily and PRN. May treat with other wound dated 10/14/20 and discontinued on 10/20/20.
--No documentation the treatment was completed on 10/14/20, 10/15/20, 10/16/20, 10/17/20, and 10/19/20.
-Left lateral back dressing, cleanse area with wound cleanser apply collagen to wound bed. Spray periwound with non-sting barrier. Protect with ABD thick wound dressing. Adhere with Medipore tape. Treat daily and PRN. May treat with other wound dated 10/14/20 and discontinued on 10/20/20.
--No documentation the treatment was completed on 10/14/20, 10/15/20, 10/16/20, 10/17/20, and 10/19/20
-Negative Pressure Wound Treatment to be applied to the resident's left lower back set at 125 mm. Dressing changed every Monday, Wednesday, and Friday scheduled during the day shift. Check every shift. Dated 10/20/20 with a start date on 10/20/20. No documentation the staff completed the treatment between 10/20/20 - 10/22/20.
-Negative Pressure Wound Treatment to be applied to the resident's left lateral back set at 125 mm. Dressing changed every Monday, Wednesday, and Friday scheduled during the day shift. Check every shift. Dated 10/20/20 with a start date on 10/20/20. No documentation the staff completed the treatment between 10/20/20 - 10/22/20.
Record review of the resident's Nurse's Notes dated 10/3/20 showed:
-He/She was admitted to the facility with a midline lower back wound.
-The wound had MRSA and was complicated due to resolving shingles.
-The resident's midline lower back wound was covered with a dressing that was clean, dry, and intact.
--No documentation of the resident's left lateral wound.
--No description of the wounds.
Record review of the resident's New Skin Audit Report Roster showed CNAs documented the resident did not have any new skin problems between 10/4/20 - 10/22/20.
Record review of the resident's Care Plan dated 10/6/20 showed he/she:
-Had a surgical wound.
-Staff should assess his/her skin dailiy with routine care.
-Reassess treatment plan if no healing within two to four weeks.
-Assess changes in skin status that indicate worsening of surgical wound and notify the physician.
-Wound VAC at 125 mm, continuous to mid back wound updated on 10/22/20.
Record review of the resident's Nurse's Notes dated 10/6/20 showed:
-The resident had multiple wounds on his/her back that would be looked at by the facility wound nurse.
-The resident had a follow-up with an outside wound clinic on 10/12/20.
-The wounds did not have an odor but had moderate amount of drainage.
--No documentation where the resident's wounds were located on his/her back or how many wounds the resident had on his/her back.
--No documentation of the resident's back wounds description.
Record review of the resident's electronic Wound Documentation dated 10/6/20 showed:
-The resident had a lesion wound on his/her left lower back and mid spine first identified on 10/3/20 and present upon admission to the facility.
-The wound measured 6 centimeters (cm) in length, 3.5 cm in width, and 1.3 cm in depth.
--The documentation did not identify which of the back wounds was measured.
-The wounds had a small amount of serous (watery, clear, or slightly yellow/tan/pink drainage) drainage.
-The wounds were not infected.
-the wound bed had 25 percent (%) granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) and 75% slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) with a clearly defined border and had macerated (softened by prolonged contact with liquid) edges.
--The documentation did not identify which back wound was described.
Record review of the resident's electronic Skin assessment dated [DATE] showed:
-A skin assessment was completed.
-The resident's skin was not intact and it was an existing issue.
-No documentation a skin assessment was completed prior to 10/20/20.
-No documentation what the skin issue was, where the skin issue was, or a description of the skin issue.
Observation on 10/22/20 at 2:21 P.M of the resident showed:
-He/She had a Wound VAC on his/her left lateral back wound and midline (spine) back wound.
-The wound bed was pink on the left lateral back wound and the midline back wound.
During an interview on 10/23/20 at 10:59 A.M., Registered Nurse (RN) A said:
-Staff should document a resident's skin/wounds at least weekly in the resident's electronic medical record.
-He/She could not locate any wound documentation in the resident's medical record.
-The resident was admitted with wound on his/her left lateral back and midback.
-Once the task of completing a skin assessment is completed in the computer, it drops off and goes to the DON.
-The wound nurse measures documents assessments of the residents wounds.
-The resident's TAR showed where the resident's wounds were located.
-Staff should report to the nurse if the resident's wounds were better or worse.
-He/She was not able to access the resident's wound records to see what condition the wounds were when last assessed.
During an interview on 10/23/20 at 11:47 A.M., the ADON said:
-The CNA does a daily skin sweep to assess a resident's skin condition.
-Some residents would get weekly skin assessments.
-If the resident had a new wound, staff should document it in the resident's Nursing Notes.
-Any skin abnormality should be documented in the resident's nursing notes.
-The wound nurse documents the resident's wounds on Tuesdays.
During an interview on 10/23/20 at 2:16 P.M., Physician A said:
-Staff should do a daily skin assessment if the resident had skin issues.
-If the resident did not have skin issues, he/she would expect a weekly skin assessment.
-Staff should document the resident's skin assessment, including a description of the wounds.
-The resident was admitted to the facility with two wounds on his/her back due to shingles.
During an interview on 10/26/20 at 1:56 P.M., Wound Nurse A said:
-He/She measured wounds on Tuesdays and gives the information to the ADON, DON, or charge nurse.
-He/She did not enter the wound measurements or assessments in the residents' electronic records, he/she documents the wounds on paper.
-The nurse taking care of the resident was responsible to complete the residents' skin assessments and document them in the electronic medical record.
-He/She only looks at wounds/skin he/she is aware of, he/she does not do a skin assessment on all residents in the facility.
-He/She would look at a resident's skin if the nurse asked him/her to.
During an observation and interview on 10/27/20 at 10:10 A.M., Wound Nurse A said:
-He/She cannot find the documentation he/she had done on the resident's two back wounds.
-The assessments he/she did was weekly since the resident was admitted , but he/she could not find his/her written documentation and the documentation was not entered in the resident's electronic medical record.
During an interview on 10/27/20 at 1:22 P.M., the DON said:
-Staff should do skin assessments weekly or as needed if the resident had a new skin issue.
-Wound assessments should be in the resident's chart.
-Wound assessments were completed on paper then entered into the resident's electronic medical record.
-Staff could have accessed the resident's paper documentation.
-The paper documentation was kept in the conference room (and not in the resident's chart or at the nurse's station).
-He/She could not find the resident's wound assessments after 10/6/20.
Based on observation, interview and record review, the facility failed to identify, notify the physician, obtain treatment orders and complete an incident report and investigation for one sampled resident (Resident #18) who had right lower leg abrasions; to ensure one sampled resident (Resident #51) had a hospice (end of life care) book with a clear integrated plan on how to care for the resident at his/her end of life; and to monitor a resident's non-pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failing to complete weekly skin and/or wound assessments for one sampled resident (Resident #62) out of 17 sampled residents. The facility census was 68 residents
Record review of the facility's Terminally Ill - Caring For policy updated 11/1/2001 showed:
-The resident's family, friends and clergy should be encouraged to play an active role in the psychosocial plan of care for the terminally ill resident.
-Hospice services may be offered to terminally ill residents.
-The policy did not contain information related to the coordination of care between the facility and hospice services.
Record review of the facility's policy Incidents and Accidents updated 11/10/14 showed:
-An incident was an occurrence that may not be consistent with the routine operations of the facility or routine care.
-Examples include but were not limited to skin tears or bruising.
-Process:
--The resident should be assessed for injury, pain, range of motion, bruising, bleeding and lacerations.
--The physician should be notified and physician's orders should be obtained.
-The resident's family should be notified.
-Interventions should be documented in the nurse's notes and the incident noted on the 24 hour report.
-An incident report should be completed.
-A brief investigation should be developed.
Record review of the facility's Protocol for Certified Nursing Assistant (CNA) and Licensed Nurse Skin Inspections policy dated 10/1/10 showed:
-CNA's will conduct body inspections of residents at risk for pressure ulcers on a daily basis.
-Licensed Nurses will conduct body inspections of residents at risk for pressure ulcers on a weekly basis.
-CNAs will conduct a body inspection on all assigned residents.
-Results of inspection will be documented on the body audit sheet or in the electronic charting beside the resident's name.
-Any skin concern identified by the CNA will be reported to the assigned Licensed Nurse immediately.
-The CNA will document the nurse it was reported to on the body audit sheet or report changes recorded in the electronic charting.
-Designated Licensed Nurse will conduct body inspection on all residents on a weekly basis, per schedule.
-The Director of Nursing (DON) will ensure that a weekly schedule is developed and implemented.
-Licensed Nurse will document findings of inspection on the Medication Administration Record (MAR) which is individualized for each resident.
-Any skin concerns identified by licensed nurse will be reported to the designated Treatment Nurse immediately for evaluation and treatment orders.
-If the treatment nurse is not available, the nurse identifying the concern should evaluate the wound and notify the resident's physician for initial treatment orders.
-Weekly results will be reviewed at the Quality Assurance (QA) Skin Sub-committee meeting.
-CNA body audit records will be maintained in the DON office for 90-days in a QA binder if manual sheets and reviewed by the DON if electronic.
1. Record review of Resident #18's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Cerebrovascular Accident (CVA, stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke).
-Hemiplegia/hemiparesis (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain).
-Other speech/language deficits following a stroke.
-Peripheral Vascular Disease (PVD - inadequate flow of blood to the extremities)
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
Record review of the resident's Care Plan updated 5/8/20 showed the resident:
-Used an electric wheelchair for mobility.
-Was independent with his/her electric wheelchair but needed education at times related to safety.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 7/22/20 showed he/she:
-Was severely cognitively impaired.
-Was independent with transfers.
-Used a wheel chair for mobility.
Record review of the resident's Physician's Orders Sheet (POS) dated 10/2020 showed there were no physician's orders related to any right leg abrasions.
Observation on 10/19/20 at 12:22 P.M. showed the resident:
-Was in the hallway in his/her electric wheelchair.
-Had lower leg abrasions on the front of his/her right lower leg.
Record review of the resident's Nurses Notes dated 10/1/20 through 10/20/20 showed there were no nurses notes related to any right leg abrasions.
Record review of the resident's Skin Audit Report dated 10/1/20 through 10/20/20 showed he/she did not have any new skin problems.
Observation on 10/21/20 at 9:11 A.M. showed the resident:
-Was in the hallway in his/her electric wheelchair.
-Had a two inch thick scabbed area to his/her right lower leg which had red edges.
-Had two dime sized scabbed areas below the larger scabbed area.
-Had two pea sized scabbed areas above the larger scabbed area.
-Abrasions areas were healing.
During an interview on 10/21/20 at 9:12 A.M., the resident said he/she ran into his/her bed with the electric wheelchair which caused the right lower leg abrasions a few weeks ago.
Record review of the resident's electronic medical record on 10/21/20 showed there were no nurses notes related to the injury, no physician's orders to treat the injury, no notification of the resident's physician, and no incident report related to the residents lower leg abrasions.
During an interview on 10/21/20 at 10:07 A.M., CNA B said:
-He/she was not sure about the abrasions on the resident's right leg because he/she was off for a week.
-He/she had not noticed any abrasions on the resident's right lower leg the previous week.
During an interview on 10/22/20 at 1:45 P.M. the Administrator said:
-He/she could not locate any information including an incident report, any notes or treatments regarding the resident's right lower leg abrasions.
Observation on 10/23/20 at 10:44 A.M. showed the resident:
-Was in the hallway in his/her electric wheelchair.
-Lower leg abrasions were visible and not covered.
Observation on 10/26/20 at 9:12 A.M. showed:
-The resident was in the hallway in his/her electric wheelchair.
-The resident had a large white gauze dressing covering the resident's lower leg abrasions.
During an interview on 10/27/20 at 9:38 A.M., Licensed Practical Nurse (LPN) B said:
-If an injury occurs the nurse was responsible for completing the incident report, notifying the physician of the injury and obtaining physician's orders for the injury.
-Skin assessments were done weekly by nurses.
-If a CNA saw an area of abrasions on a resident, the CNA was responsible for notifying the charge nurse.
-He/she was unaware of any abrasions on the resident's right lower leg.
During an interview on 10/27/20 at 10:08 A.M., LPN A said:
-If a resident received an injury with abrasions, he/she was unsure if an incident report needed to be completed.
-He/she would ask the DON if an incident report needed to be completed.
During an interview on 10/27/20 at 12:16 P.M. the Assistant Director of Nursing (ADON), the DON, and the Regional Nurse Consultant (previously the interim DON) said:
The charge nurse was responsible for completing incident reports when an injury occurs.
-Management would then complete and investigation related to the incident that occurred.
-An incident report should have been completed and the nurse should have called the resident's physician for orders.
-Should the nurse notify physician and family when incidents occur.
-The resident's lower leg wounds should have been captured on a skin assessment.
2. Record review of Resident #51's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Malignant neoplasm (cancer) of an unspecified site.
-Secondary cancer to the bones and lungs.
Record review of the resident's POS showed the following physician's orders dated 9/12/20:
-Admit to hospice (end of life services) for a diagnosis of breast cancer.
-Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest)
Record review of the resident's admission MDS dated [DATE] showed he/she:
-Was cognitively intact.
-Required the assistance of two staff members with transfers, bed mobility and dressing.
-Was on hospice services.
Record review of the resident's Social Services notes dated 9/17/20 showed:
-The resident was admitted to the facility from the hospital.
-The resident was a long-term care resident and was admitted to hospice services.
Record review of the resident's hospice care plan dated 9/19/20 showed:
-The staff needed to respect the resident's wishes of his/her DNR status.
-The staff needed to provide comfort measures and pain management as needed.
-The staff needed to inform other healthcare institutions caring for him/her of the DNR status.
-There was no documentation that showed and integrated care plan between the facility and hospice services.
Observation on 10/21/20 at 5:15 A.M. showed the resident was in bed, awake, but did not respond when asked a question.
During an interview on 10/21/20 at 5:58 A.M. LPN E said:
-The resident was at end of life.
-The resident was not getting up out of bed anymore.
During an interview on 10/19/20 at 11:28 A.M. Registered Nurse (RN) A said:
-The resident was on hospice services.
-He/she had not seen hospice staff visit the resident.
-He/she was unsure of the resident's diagnosis.
During an interview on 10/21/20 at 6:39 A.M. LPN E said:
-He/she could not locate the resident's hospice book.
-He/she was new to the facility.
-The hospice books were located behind the nurses station.
Observation on 10/21/20 at 6:41 A.M. showed there was no hospice book behind the nurses station for the resident.
During an interview on 10/21/20 at 9:34 A.M. LPN D said:
-He/she could not locate the resident's hospice book.
-He/she was unsure how long the hospice book had been missing.
During an interview on 10/21/20 at 9:42 A.M. the Social Services Director (SSD) said
-The resident was on hospice services.
-The SSD looked for the resident's hospice book behind the nurses station and could not locate it.
During an interview on 10/21/20 at 10:31 A.M. the DON said:
-The hospice books were located under the desk at the nurses station.
-He/she was trying to locate the resident's hospice book now.
-The resident should have a hospice book.
During an interview on 10/22/20 at 9:54 A.M. the Administrator said:
-He/she only located an empty hospice book.
-He/she was going to call hospice and obtain the resident's hospice records.
During an interview on 10/26/20 at 10:19 A.M. the MDS Coordinator said:
-He/she was not sure if hospice had been in to see the resident.
-The resident was mainly needing to be monitored for pain control.
-He/she was only aware the hospice staff assessed the resident but not sure about ongoing visits.
-Hospice was responsible for developing an integrated care plan for the resident.
During an interview on 10/27/20 at 9:38 A.M., LPN B said:
-The resident was on hospice services and should have a hospice book related to hospice staff visits.
-The resident should have a care plan but he/she was not sure who developed the integrated hospice care plan.
During an interview on 10/27/20 at 10:08 A.M., LPN A said:
-The resident should have a hospice book at the nurses station.
-The hospice book should include the contact information for hospice.
-He/she was unsure if the book should contain any hospice visit information.
-He/she would assume there should be visit information with cares provided and nurses assessments by hospice.
During an interview on 10/27/20 at 12:16 P.M. the ADON, the DON, and the Regional Nurse Consultant (previously the interim DON) said:
-The MDS Coordinator was responsible for updating the care plans, the nurse and nurse management.
-Each care plan should have individualized interventions and goals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 monitor a resident's pressure ulcer (localized injury...
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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 monitor a resident's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failing to complete weekly skin and/or wound assessments for one sampled resident (Resident #62) out of 17 sampled residents. The facility census was 68 residents.
Record review of the facility's Protocol for Certified Nursing Assistant (CNA) and Licensed Nurse Skin Inspections policy dated 10/1/10 showed:
-CNA's will conduct body inspections of residents at risk for pressure ulcers on a daily basis.
-Licensed Nurses will conduct body inspections of residents at risk for pressure ulcers on a weekly basis.
-CNAs will conduct a body inspection on all assigned residents.
-Results of inspection will be documented on the body audit sheet or in the electronic charting beside the resident's name.
-Any skin concern identified by the CNA will be reported to the assigned Licensed Nurse immediately.
-The CNA will document the nurse it was reported to on the body audit sheet or report changes recorded in the electronic charting.
-Designated Licensed Nurse will conduct body inspection on all residents on a weekly basis, per schedule.
-The Director of Nursing (DON) will ensure that a weekly schedule is developed and implemented.
-Licensed Nurse will document findings of inspection on the Medication Administration Record (MAR) which is individualized for each resident.
-Any skin concerns identified by licensed nurse will be reported to the designated Treatment Nurse immediately for evaluation and treatment orders.
-If the treatment nurse is not available, the nurse identifying the concern should evaluate the wound and notify the resident's physician for initial treatment orders.
-Weekly results will be reviewed at the Quality Assurance (QA) Skin Sub-committee meeting.
-CNA body audit records will be maintained in the DON office for 90-days in a QA binder if manual sheets and reviewed by the DON if electronic.
1. Record review of Resident #62's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Cellulitis (an infection of deep skin tissue).
-Zoster with other complications (shingles - A reactivation of the chickenpox virus in the body, causing a painful rash that may appear as a stripe of blisters on the trunk of the body. Pain can persist even after the rash is gone).
-Methicillin Resistant Staphylococcus Aureus (MRSA - a type of bacteria that is resistant to many antibiotics).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behavioral disturbance.
-Pressure ulcer of the sacral regions (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity), Stage III wound (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling).
Record review of the resident's Hospital to Long-Term Care Handoff Nursing Communication forms dated 10/3/20 showed:
-The resident had a pressure ulcer.
-A body diagram had the pressure ulcer circled at the sacral region.
-The resident was at risk of skin breakdown.
Record review of the resident's Physician's Order Sheet (POS) dated October 2020 showed:
-Observe the dressing to the coccyx (tailbone) every shift. See as needed (PRN) order as needed for dressing change dated 10/7/20.
-Stage III pressure ulcer to the coccyx, treat every Tuesday and Friday and as needed. Cleanse with wound cleanser. Apply non-sting barrier to the periwound (skin around the wound). Protect with Tegaderm Hydrocolloid Thin (a dressing) dated 10/7/20.
-Stage III pressure ulcer to the coccyx, treat every Tuesday and Friday and as needed. Cleanse with wound cleanser. Apply non-sting barrier to the periwound. Protect with Tegaderm Hydrocolloid Thin, schedule at 11:00 P.M., dated 10/7/20.
Record review of the resident's MAR dated October 2020 showed:
-Skin Audit to be done weekly, record 0 for no new skin problems and 1 for new skin problems, follow up in notes dated 10/3/20.
-Two skin assessments were checked as being completed.
-On 10/10/20 staff documented 0 - no, indicating the resident did not have a new skin problem.
-On 10/17/20 staff documented 0 - no, indicating the resident did not have a new skin problem.
Record review of the resident's Treatment Administration Record (TAR) dated October 2020 showed:
-Stage III pressure ulcer to the coccyx, treat every Tuesday and Friday and as needed. Cleanse with wound cleanser. Apply non-sting barrier to the periwound. Protect with Tegaderm Hydrocolloid Thin, schedule at 11:00 P.M., dated 10/7/20 and discontinued on 10/17/20.
--Staff documented the treatment was completed on 10/9/20, 10/13/20, and 10/16/20.
-Stage III pressure ulcer to the coccyx, treat every Tuesday and Friday and as needed. Cleanse with wound cleanser. Apply non-sting barrier to the periwound. Protect with Tegaderm Hydrocolloid Thin, schedule at 11:00 P.M., dated 10/17/20.
--Staff documented the treatment was completed on 10/20/20.
--NOTE: No documentation a treatment was ordered or completed for the Stage III pressure ulcer on the resident's coccyx between 10/3/20 - 10/7/20.
Record review of the resident's Nurse's Notes dated 10/3/20 showed:
-He/She was admitted to the facility with a Stage III pressure ulcer on his/her coccyx/sacral area.
-The pressure ulcer had a dressing that was in place, dry, and intact.
--NOTE: the note did not describe the wound's appearance.
Record review of the resident's New Skin Audit Report Roster showed CNAs documented the resident did not have any new skin problems between 10/4/20 - 10/22/20.
Record review of the resident's medical record showed no documentation staff completed a Braden scale (a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers) between 10/4/20 - 10/22/20.
Record review of the resident's weight showed his/her weight on 10/5/20 was 141 pounds.
Record review of the resident's Care Plan dated 10/6/20 showed he/she:
-Was at risk for skin breakdown.
-Staff should complete a skin audit per schedule.
Record review of the resident's electronic Wound Documentation dated 10/6/20 showed:
-The resident had a stage III pressure ulcer to his/her coccyx/sacrum measuring 3.0 centimeters (cm) in length by 0.5 cm in width by 0.2 cm in depth. The pressure ulcer had 50 percent (%) granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) and 50% slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). The wound border definition was indistinct, diffuse, and not clearly visible. The surrounding skin was pink with slight edema (swelling).
-The pressure ulcer was present upon admission to the facility.
-No documentation the resident's Stage III pressure ulcer was measured, assessed, or monitored after 10/6/20.
Record review of the resident's weight showed his/her weight on 10/13/20 was 129 pounds.
Record review of the resident's Resident Risk Review for Pressure Ulcers 10/19 dated 10/13/20 showed he/she:
-Had a pressure ulcer of his/her sacral region, Stage III.
-Had a previous pressure ulcer Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) or greater.
-Had skin desensitization to pain for pressure, neuropathy (damage to the nerves resulting in sensory loss in the extremities), paresthesis (a sensation of pins and needles, caused chiefly by pressure on or damage to peripheral nerves), and paralysis (complete or partial loss of muscle function).
-Was debilitated (in a very weakened and infirm state).
-Had cognitive impairment.
-Was non-compliant with care.
-Had impaired/decreased mobility/decreased functional ability.
-Was at risk of developing pressure ulcers.
-The box for Full body assessment completed was left blank.
Record review of the resident's weight showed his/her weight on 10/16/20 was 130 pounds.
Observation of the resident's Low Air Loss Mattress (LALM - a speciality mattress) on 10/19/20 showed the mattress was set at 170 pounds.
Record review of the resident's electronic Skin assessment dated [DATE] showed:
-A skin assessment was completed.
-The resident's skin was not intact and it was an existing issue.
-No documentation a skin assessment was completed prior to 10/20/20.
-No documentation what the skin issue was, where the skin issue was, or a description of the skin issue.
Observation on 10/20/20 at 11:52 A.M. showed the resident's LALM was set at 170 pounds.
Observation on 10/21/20 at 5:49 A.M., of the resident showed the resident was resting in bed with his/her eyes closed. His/Her LALM was set at 200 pounds.
Observation on 10/22/20 at 10:02 A.M., of the resident showed:
-The resident was transferred to his/her bed from his/her wheelchair.
-The resident's LALM was set at 200 pounds.
Observation on 10/22/20 at 2:21 P.M of the resident showed:
-He/She did not have a dressing on his/he coccyx/sacral area.
-The resident's coccyx/sacral area had a linear open area which appeared to be healing with minimal depth.
-The resident's LALM was set at 200 pounds.
-Had an abnormal skin area to his/her right heel that appeared to be an old blister that was healing.
During an interview on 10/22/20 at 2:30 P.M., the DON said the resident's right heel appeared to be an old blister that had healed.
During an interview on 10/23/20 at 10:59 A.M., Registered Nurse (RN) A said:
-Staff should document a resident's skin/wounds at least weekly in the resident's electronic medical record.
-He/She could not locate any wound documentation in the resident's medical record.
-The resident was admitted with a pressure ulcer to his/her coccyx.
-Once the task of completing a skin assessment is completed in the computer, it drops off and goes to the DON.
-The wound nurse stages the pressure ulcers.
-The resident's TAR showed where the resident's wounds were located.
-Staff should report to the nurse if the resident's wounds were better or worse.
-He/She was not able to access the resident's wound records to see what condition the wounds were when last assessed.
-He/She was not aware of any skin abnormalities on the resident's right heel.
Observation on 10/23/20 at 11:25 A.M. showed the resident's LALM was set at 200 pounds.
During an interview on 10/23/20 at 11:47 A.M., the Assistant Director of Nursing (ADON) said:
-The Certified Nursing Assistant (CNA) does a daily skin sweep to assess a resident's skin condition.
-Some residents would get weekly skin assessments.
-If the resident had a new wound, staff should document it in the resident's Nursing Notes.
-Any skin abnormality should be documented in the resident's nursing notes.
-The wound nurse documents the resident's wounds on Tuesdays.
During an interview on 10/23/20 at 2:16 P.M., Physician A said:
-Staff should do a daily skin assessment if the resident had skin issues.
-If the resident did not have skin issues, he/she would expect a weekly skin assessment.
-Staff should document the resident's skin assessment, including a description of the wounds.
-He/She was not aware of the resident's coccyx wounds, but the facility wound nurse would be more aware of the resident's wounds.
-He/She was not aware of any skin abnormality on the resident's right heel.
Observation on 10/26/20 at 11:23 A.M. showed the resident's LALM was set at 200 pounds.
During an interview on 10/26/20 at 1:56 P.M., Wound Nurse A said:
-He/She measured wounds on Tuesdays and gives the information to the ADON, DON, or charge nurse.
-He/She did not enter the wound measurements or assessments in the residents' electronic records, he/she documents the wounds on paper.
-The nurse taking care of the resident was responsible to complete the residents' skin assessments and document them in the electronic medical record.
-He/She only looks at wounds/skin he/she is aware of, he/she does not do a skin assessment on all residents in the facility.
-He/She would look at a resident's skin if the nurse asked him/her to.
-The resident was admitted to the facility with a pressure ulcer to his/her coccyx.
-The resident's pressure ulcer has improved since he/she was admitted to the facility.
-The resident's LALM should be set at the resident's weight.
-He/She was not aware of any skin abnormalities to the resident's right heel.
Observation of the resident on 10/27/20 at 9:19 A.M. with CNA E showed the top edge of the skin abnormality on the resident's right heel was missing.
During an interview on 10/27/20 at 9:20 A.M., CNA E said:
-He/She noticed the skin abnormality on the resident's right heel on 10/22/20 and reported it to the DON.
-He/She checks the LALM to make sure it is on and inflated.
-he/She was not sure what the LALM setting should be on, the nurse does that.
During an observation and interview on 10/27/20 at 10:10 A.M., Wound Nurse A said:
-The resident's right heel looked like it had been an old blister that had healed.
-The DON had talked to the resident's outside wound clinic last week and found out that the heel was an old wound that they (the outside wound clinic) was not concerned about it.
-He/She cannot find the documentation he/she had done on the resident's coccyx pressure ulcer.
-The assessments he/she did was weekly since the resident was admitted , but he/she could not find his/her written documentation and the documentation was not entered in the resident's electronic medical record.
Observation on 10/27/20 at 1:12 P.M. showed the resident's LALM was set at 200 pounds.
During an interview on 10/27/20 at 1:22 P.M., the DON said:
-A LALM should be set at the resident's weight.
-Staff should do skin assessments weekly or as needed if the resident had a new skin issue.
-Wound assessments should be in the resident's chart.
-Wound assessments were completed on paper then entered into the resident's electronic medical record.
-Staff could have accessed the resident's paper documentation.
-The paper documentation was kept in the conference room (and not in the resident's chart or at the nurse's station).
-He/She could not find the resident's wound assessments after 10/6/20.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain communication between the facility and the di...
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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 communication between the facility and the dialysis center and to develop a dialysis policy that instructed staff regarding communication between the facility and the dialysis center for one sampled resident (Resident #58) who received dialysis (use of a machine to purifying the blood of a person whose kidneys are not working adequately to sustain life) out of 17 sampled residents. The facility census was 68 residents.
Record review of the facility Hemodialysis (removing waste products from a person's blood) Care policy dated 11/1/01 showed:
-Obtain dry weights from the dialysis center.
-Obtain lab work from the dialysis center.
-The policy did not include specific instruction regarding how to maintain communication between the facility and the dialysis center.
1. Record review of Resident #58's Face Sheet showed he/she was readmitted to the facility on [DATE] with a diagnosis of end stage renal failure (the last stage of chronic kidney failure in which dialysis treatment is required).
Record review of the resident's Physician's Orders Sheet (POS) dated 10/2020 showed:
-Diagnoses of end stage renal failure and dependence on renal dialysis.
-Assess dialysis site (fistula - the vein and artery that were surgically joined, to provide large vein access for hemodialysis) after dialysis for bruit and thrill (rumbling or swooshing sound of a dialysis fistula heard with a stethoscope) and thrill (the vibration felt on the skin overlying the dialysis fistula); if not present call physician; monitor for bleeding, if present call physician.
-Resident attended dialysis three days weekly.
Observation on 10/20/20 at 11:29 A.M. showed:
-He/she was alert, sitting on his/her bed in his/her room.
-He/she had a dressing on his/her left arm over his/her dialysis fistula.
-He/she said he/she went to dialysis three days a week and that facility nurses listen to and touch his/her dialysis fistula every day.
Observation on 10/26/20 at 8:57 A.M. showed:
-The resident was alert and sitting on his/her bed in his/her room.
-The resident's left arm dialysis fistula was had no redness.
During an interview on 10/26/20 at 12:12 P.M. Licensed Practical Nurse (LPN) A said:
-He/she assesses the resident's dialysis site every shift and on his/her dialysis days both before and after his/her dialysis.
-He/she listens for the bruit and feels for the thrill, assesses for any bleeding, and for any redness or signs of infection.
-He/she was not aware of any notebook, forms or other communication system between the facility and the dialysis center; he/she had never seen a notebook or any forms.
-There was no wet/dry weight (weights before, i.e. wet and after dialysis, i.e. dry) report to the facility from the dialysis center each time the resident went to the dialysis center.
-The facility did not monitor the resident's weight related to the resident's dialysis.
-The dialysis center did sometimes send labs or other information back to the facility and he/she filed the information in the resident's hard chart kept at the nurse's station.
Record review of the resident's medical records on 10/26/20 showed no documentation of ongoing communication between the facility and the dialysis center on the resident's dialysis days.
During an interview on 10/27/20 at 12:40 P.M. the Director of Nursing (DON) and corporate Regional Nurse said:
-Facility licensed nurses and the resident's dialysis center routinely communicated regarding the resident on forms provided by the facility.
-They expected the facility licensed nurses and the dialysis to communicate each dialysis appointment regarding the residents pre and post dialysis weights, his/her vital signs, the assessment of his/her site (fistula), any new orders and how long the dialysis run was.
-The facility had a form that was supposed to be filled out by the dialysis center and sent back to the facility when the resident returned to the facility from his/her dialysis appointments.
-They would provide the forms to the surveyor.
-The facility charge nurse sometimes called the dialysis center and the dialysis center sometimes called the facility regarding the resident.
-As of 11/5/20 at 5:00 P.M. the survey team had not received dialysis communication forms for the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) and/or the Notice of Medicare Provider Non-Cover...
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Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) and/or the Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) for three sampled residents (Resident #7, #277, and #278) out of three sampled residents who were discharged from Medicare part A services. The facility census was 68 residents.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following:
-The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) was issued when all covered Medicare services end for coverage reasons.
-If the skilled nursing facility (SNF) believed on admission or during a resident's stay that Medicare would not pay for skilled nursing or specialized rehabilitative services and the provider believed that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters.
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have.
-If the SNF provided the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider had met the obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination.
1. Record review of the facility's Beneficiary Notice-Resident's discharged in the Last Six Months report showed Resident #277 discharged from Medicare Part A services back to long term care on 8/20/20 and remained in the facility.
Record review of the residents SNF Beneficiary Protection Notification Review form showed:
-The resident was admitted for Medicare Part A services on 7/21/20.
-The resident discharged from Medicare Part A services on 8/20/20.
-There were no attachments that showed a NOMNC or SNFABN had been provided to the resident or the resident's responsible party.
-The staff wrote SNFABN and NOMNC unable to locate in resident file.
2. Record review of the facility's Beneficiary Notice-Resident's discharged in the Last Six Months report showed Resident #278 discharged from Medicare Part A services to home on 9/11/20.
Record review of the residents SNF Beneficiary Protection Notification Review form showed:
-The resident was admitted for Medicare Part A services on 7/30/20.
-The resident discharged from Medicare Part A services on 9/11/20.
-The attached NOMNC showed the resident's current therapy stay would end on 9/11/20. No signature was on the form showing the resident or the resident's responsible party were provided the form or the right to appeal the discharge.
3. Record review of the facility's Beneficiary Notice-Resident's discharged in the Last Six Months report showed Resident #7 discharged from Medicare Part A services back to long term care on 7/14/20 and remained in the facility.
Record review of the residents SNF Beneficiary Protection Notification Review form showed:
-The resident was admitted for Medicare Part A services on 7/1/20.
-The resident discharged from Medicare Part A services on 7/14/20.
-The staff wrote SNFABN unable to locate in resident file.
4. During an interview on 10/22/20 at 1:50 P.M. the Regional Financial Specialist said:
-There was not a staff member in the Business Office Manager (BOM) position at that time.
-He/she had been filling in and completing the SNFABN and NONMCs.
-The BOM was responsible for ensuring the residents and/or the resident's responsible party received the SNFABNs and the NOMNCs.
-After morning meeting, the BOM would prepare the NOMNC and SNFABN if needed after all skilled residents were discussed.
-The BOM was responsible for calling the residents responsible party, family, legal guardian and review the notices over the phone due to COVID 19 (a new disease caused by a novel (new) coronavirus) restrictions.
-The BOM was responsible for mailing a copy to the resident's responsible party and/or the resident.
-The NOMNC and SNFABN was to be provided to the resident and/or resident's responsible party at least three days prior to discharge.
-The SNFABNs were to be provided to the residents and/or the resident's responsible party for residents who stayed in the facility after discharging from Medicare Part A services.
During an interview on 10/27/20 at 12:16 P.M. the ADON, the DON, and the Regional Nurse Consultant (previously the interim DON) said:
-The BOM was responsible for ensuring the resident's receive the NOMNC and the SNFABNs.
-The resident should be given the notices 48 hours prior to discharge off of Medicare Part A services.
A policy was requested from the facility and was not received.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to check the Certified Nursing Assistant (CNA) Registry to ensure individuals did not have a Federal Indicator (a marker given by the federal ...
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Based on record review and interview, the facility failed to check the Certified Nursing Assistant (CNA) Registry to ensure individuals did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect) for four sampled employees (Employees A, C, D, and E), out of six sampled employees hired since the last annual survey. The facility census was 68 residents.
Record review of the facility Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injury of Unknown Source, and Exploitation policy dated 11/28/17 and revised on 2/18/18 showed:
-The facility will not knowingly employ or otherwise engage any individual who has been found guilty by a court of law of abusing, neglecting, or mistreating resident.
-In addition, the facility will not knowingly employ any individual who had a finding entered into the state nurse aide registry or disciplinary action against his or her professional license, concerning abuse, neglect, and mistreatment of resident, exploitation or misappropriation of resident property.
-The facility will also refrain from employing any individual who has been prohibited from working in a long term care facility for any other reason.
-To ensure that the facility does not knowingly hire such an individual, the facility will search the appropriate registries and will conduct a background investigation to determine whether a finding of abuse, neglect, mistreatment, exploitation or misappropriation has been entered against a potential employee.
--This search will include all registries that the facility believes may have information.
1. Record review of Employee A's file showed:
-He/she was hired on 11/11/19.
-There was no record of the CNA Registry being checked prior to or upon hire.
2. Record review of Employee C's file showed:
-He/she was hired on 9/17/20.
-There was no record of the CNA Registry being checked prior to or upon hire.
3. Record review of Employee D's file showed:
-He/she was hired on 3/12/20.
-There was no record of the CNA Registry being checked prior to or upon hire.
4. Record review of Employee E's file showed:
-He/she was hired on 8/22/19.
-There was no record of the CNA Registry being checked prior to or upon hire.
During an interview on 10/27/20 at 3:36 P.M., the Business Office Manager said:
-He/She would complete a CNA Registry check for any staff hired in a nursing position,
-The staff in question were hired before he/she started at the facility.
-He/She was not aware a CNA Registry check should be completed for all staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #62's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #62's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Cellulitis (an infection of deep skin tissue).
-Zoster with other complications (shingles - A reactivation of the chickenpox virus in the body, causing a painful rash that may appear as a stripe of blisters on the trunk of the body. Pain can persist even after the rash is gone).
-Methicillin Resistant Staphylococcus Aureus (MRSA - a type of bacteria that is resistant to many antibiotics).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behavioral disturbance.
Record review of the resident's Care Plan dated 10/6/20 showed he/she:
-Required staff assistance to complete daily activities of care safely.
-Staff were to provide him/her with assistance for bathing as needed.
Record review of the facility's New Bath Report Roster showed the resident had not received a bath or shower between 10/4/20 - 10/26/20.
4. During an interview on 10/21/20 at 10:07 A.M., Certified Nurses Assistant (CNA) B said:
-Bath Aide/CNA C was assigned to bathing and had a set schedule for bathing.
-He/she did know the bath aide did get pulled to work the floor.
-He/she did get pulled quite a bit to work the floor.
-Sometimes, the management would try to get someone to cover but this was not often.
-Residents complain about not getting baths/showers.
-Some residents would get really upset about not getting showers and voice their concerns about not getting a shower.
-He/she would leave a note or tell Bath Aide/CNA C who needed a bath.
-He/she would also notify the charge nurse, whoever was there that day.
During an interview on 10/21/20 at 10:44 A.M. Bath Aide/CNA C said:
-He/she did everything possible to give all residents a shower every week.
-He/she was supposed to offer the residents at least two baths a week.
-He/she was the only bath aide for the whole building.
-He/she had a bathing schedule but he/she could not shower all of them due to the amount of residents who need a shower.
-He/she did get pulled to work the floor.
-Last week he/she was pulled to work on the floor three days out of five days including one overnight.
-He/she did try to get a few showers done when he/she worked the floor.
-He/she came in early at 4:30 A.M. for residents who want an early bath.
-Usually, he/she started at 5:30 A.M. in the morning.
-Some night staff would give bed baths for residents who have heavy incontinence but he/she was not sure if this was documented.
-Resident #64 typically received a shower one to two times a week.
-The last time he/she bathed Resident #64, was eight days ago.
-He/she charted this in the ADL section of the e-chart when a bath was given.
-There was no written schedule on who was to be bathed when.
-He/she would pull a bath audit and see who had not had a bath in the last seven days then work off of this report.
-He/she would give baths to the ones who had not had a bath in the last seven days.
During an interview on 10/23/20 at 12:25 P.M., CNA D said:
-Bath Aide/CNA C was responsible for resident showers.
-Residents who request a shower or had not had a shower for a while were the top priority.
-Bath Aide/CNA C would get pulled to work the floor instead of giving residents showers.
During an interview on 10/23/20 at 1:08 P.M. Bath Aide/CNA C said:
-He/she was pulled to work the floor on the front hall.
-He/she was not doing showers today for the residents.
During an interview on 10/27/20 at 9:38 A.M., Licensed Practical Nurse (LPN) B said:
-The facility only had one bath aide right now.
-The bath aide would get pulled to work on the floor instead of doing baths.
-The facility was in process of hiring another bath aide.
-The residents should have a bath at least twice a week.
During an interview on 10/27/20 at 10:08 A.M., LPN A said:
-The bath aide was responsible for resident showers.
-The residents should have two to three baths per week.
-The bath aide got pulled to the floor to work quite often.
During an interview on 10/27/20 at 12:16 P.M. the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Regional Nurse Consultant (previously the interim DON) said:
-If they did not have a bath aide the CNA's should be doing bed baths if they cannot get them to a shower.
-He/she was not aware of any audits for showers.
-He/she was going to start charting the residents bath days with schedule on a calendar to be able to audit bathing.
-He/she thought the residents' baths were not getting charted appropriately.
-He/she was not aware of any residents complaining of not getting a bath in two weeks.
-If someone looked like they did not have a bath, he/she would work on getting the resident a bath.
-Some residents would go one week without a bath maybe.
-He/she was aware that only one bath was getting done per resident.
-He/she was working on getting another bath aide because one bath aide cannot do 140 baths a week.
-Each resident should receive two baths per week.
-The bath aide was pulled to the floor to work but he/she could not give an average of how often.
Complaint MO00175227
Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out bathing needs received showers or baths to maintain good personal hygiene for two sampled residents (Resident #64 and #62) out of 17 sampled residents and for one closed record resident (Resident #271) out of three closed records. The facility census was 68 residents.
Record review of the facility's Bath-Shower or Tub policy dated 10/1/10 showed:
-Showers and baths promote cleanliness and comfort for the resident.
-Residents should receive a shower or tub bath as needed.
1. Record review of Resident #64's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Major depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Stroke.
Record review of the resident's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) care plan updated 3/20/20 showed no bathing preference or level of assistance needed for bathing.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated tool required to be completed by the facility staff for care planning) dated 6/25/20 showed he/she:
-Was moderately cognitively impaired.
-Needed the physical assistance of one staff member with bathing.
-Was totally dependent on staff for transfers.
Record review of the resident's Bath Report dated 7/24/20 through 10/20/20 showed:
-The resident received a bath on the following dates:
-7/28/20.
-8/12/20: The resident did not have a bath/shower for fourteen days since the last documented bath/shower.
-8/21/20: The resident did not have a bath/shower for eight days since the last documented bath/shower.
-8/28/20: The resident did not have a bath/shower for seven days since the last documented bath/shower.
-9/04/20: The resident did not have a bath/shower for six days since the last documented bath/shower.
-9/10/20: The resident did not have a bath/shower for five days since the last documented bath/shower.
-9/22/20: The resident did not have a bath/shower for eleven days since the last documented bath/shower.
-9/29/20: The resident did not have a bath/shower for six days since the last documented bath/shower.
-10/9/20: The resident did not have a bath/shower for nine days since the last documented bath/shower.
-10/20/20: The resident did not have a bath/shower for ten days since the last documented bath/shower.
-There were no documented refusals of bathing/showering from the resident.
Record review of the resident's annual MDS dated [DATE] showed he/she:
-Was cognitively intact.
-Needed the physical assistance of one staff member with bathing.
-Was totally dependent on staff for transfers.
During an interview on 10/21/20 at 9:50 A.M. the resident said:
-He/she had not been getting showers and had gone eight days in-between showers.
-He/she would never turn down a shower.
-Sometimes, his/her hair was very greasy due to the lack of showers.
-The last time he/she had a shower, the bath aide cut his/her hair and cut his/her nails.
-The bath aide was very good but the management team kept pulling the bath aide to work the floor.
-This was a problem because he/she was not getting showers and liked to be clean.
-At the time of the interview, the resident looked clean and had no odors.
2. Record review of Resident #271's Face Sheet showed he/she was admitted to the facility on [DATE], discharged from the facility on 9/7/20 and had the following diagnoses:
-Muscle weakness.
-Difficulty walking.
-Dementia.
Record review of the resident's ADL care plan updated 4/25/20 showed no bathing preference or level of assistance needed for bathing.
Record review of the resident's admission MDS dated [DATE] showed he/she:
-Was severely cognitively impaired.
-Needed the extensive assistance of two staff members for transfers.
-Needed the physical assistance of one staff member with bathing.
Record review of the resident's Bath Report dated 7/20/20 through 9/7/20 showed:
-The resident received a bath on the following dates:
-7/20/20.
-7/28/20: The resident did not have a bath/shower for seven days since the last documented bath/shower.
-7/29/20.
-7/30/20.
-8/12/20: The resident did not have a bath/shower for twelve days since the last documented bath/shower.
-There were no documented baths/showers from 8/13/20 through 9/6/20.
-There were no documented refusals of bathing/showering from the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident out of 17 sampled residents. The facility census was 68 residents.
1a. Record review of the facility's Facility assessment dated [DATE] showed:
-There was no documentation that showed the residents' diseases, conditions, physical and cognitive disabilities or the facility acuity level.
-The facility did not vary staffing levels according to a prospective resident's acuity or care needs.
-Staffing:
--Current staffing was stable from day to day and shift to shift based on normal and expected care needs of the residents.
--When residents with extensive care needs are considered for admission, the administrator, admissions director, and Director of Nursing (DON) determine whether additional staffing was required or whether the admission should be refused.
--In other words, the facility did not vary staffing levels according to a prospective residents' acuity or care needs.
--Instead, we admit or refuse to admit residents based on our estimation of whether we can meet their care needs with the existing staffing model.
1b. Record review of the New Bath Report Roster dated 10/16/20 through 10/22/20 showed:
-A listing of all the residents in the building.
-Ten residents did not have a bath in the last seven days.
1c. Record review of the facility's Census List dated 10/19/20 showed on the 500 hall there were 16 residents.
Record review of the facility's staffing schedule dated 10/19/20 showed:
-No staff were listed to completed resident showers.
-No staff were listed to complete restorative nursing services.
Record review of the facility's staffing schedule dated 10/20/20 showed:
-There was one Certified Nursing Assistant (CNA) assigned to the 500 hall on all three shifts.
-No staff were listed to complete restorative nursing services.
Record review of the facility's staffing schedule dated 10/21/20 showed:
-There was one CNA assigned to the 500 hall on all three shifts.
-No staff were listed to complete restorative nursing services.
Record review of the facility's staffing schedule dated 10/22/20 showed:
-There was one CNA assigned to the 500 hall on all three shifts.
-The the Minimum Data Set (MDS-a federally mandated tool required to be completed by the facility staff for care planning) worked the night shift as a nurse.
-No staff were listed to complete restorative nursing services.
Record review of the facility's staffing schedule dated 10/23/20 showed:
-There was one CNA assigned to the 500 hall on all three shifts.
-No staff were listed to complete restorative nursing services.
Record review of the facility's staffing schedule dated 10/24/20 showed:
-There was one CNA assigned to the 500 hall on all three shifts.
-No staff were listed to completed resident showers.
-Bath Aide/CNA C worked as a CNA on the 400 hall.
-No staff were listed to complete restorative nursing services.
Record review of the facility's staffing schedule dated 10/25/20 showed:
-No staff were listed to completed resident showers.
-There was one CNA assigned to the 500 hall on all three shifts.
-No staff were listed to complete restorative nursing services.
Record review of the facility's staffing schedule dated 10/26/20 showed:
-No staff were listed to completed resident showers.
-There was one CNA assigned to the 500 hall on all three shifts.
-No staff were listed to complete restorative nursing services.
Record review of the facility's staffing schedule dated 10/27/20 showed:
-No staff were listed to completed resident showers.
-There was one CNA assigned to the 500 hall on all three shifts.
1d. Record review of Resident #64's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Major depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Stroke.
Record review of the resident's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) care plan updated 3/20/20 showed no bathing preference or level of assistance needed for bathing.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated tool required to be completed by the facility staff for care planning) dated 6/25/20 showed he/she:
-Was moderately cognitively impaired.
-Needed the physical assistance of one staff member with bathing.
-Was totally dependent on staff for transfers.
During an interview on 10/21/20 at 9:50 A.M. Resident #64 said:
-He/she has not been getting showers and had gone eight days in between showers.
-Sometimes, his/her hair was very greasy due to the lack of showers.
-The bath aide was very good but the management team kept pulling the bath aide to work the floor.
-This was a problem because he/she was not getting showers and liked to be clean.
2. During an interview on 10/21/20 at 10:07 A.M., CNA B said:
-Bath Aide/CNA C was assigned to bathing and has a set schedule for bathing.
-He/she did know the bath aide did get pulled to work the floor quite a bit.
-Sometimes, management would try to get someone to cover resident showers but this was not often.
-Residents complained about not getting baths/showers.
-Some residents would get really upset about not getting showers and voice their concerns about not getting a shower.
During an interview on 10/21/20 at 10:44 A.M. Bath Aide/CNA C said:
-He/she did everything possible to give all residents one shower every week.
-He/she was supposed to offer the residents at least two baths a week.
-He/she was the only shower aide for the whole building.
-He/she was not able to shower the amount of residents that needed a shower.
-He/she did get pulled to work the floor.
-Last week he/she was pulled to three days out of five days last week including one overnight.
-He/she did try to get a few showers done when he/she worked the floor.
-He/she would get pulled sporadically to work the floor and also work to assist with resident.
-He/she came in early at 4:30 A.M. for residents who want an early bath.
-Usually, he/she started at 5:30 A.M.
-Some night staff would give bed baths for residents who have heavy incontinence but not sure if this was documented.
-There was no written schedule on who was to be bathed when.
-He/she would pull a bath audit and see who had not had a bath in the last seven days then work off of this report.
-He/she would give baths to the residents who had not had a bath in the last seven days.
During an interview on 10/23/20 at 11:52 A.M. the Activity Director said:
-He/she was the only staff member assisting the residents with activities.
-There were no other activity staff.
-He/she was responsible for completing the residents' activity assessments annually and quarterly.
-He/she had not been able to complete the activity assessments because he/she also worked on the floor as a Certified Medication Technician (CMT).
-He/she would try to do activity related tasks about 30 hours per week.
-He/she spent about ten hours per week working on the floor assisting residents.
-He/she would help answer resident call lights also.
During an interview on 10/23/20 at 12:25 P.M., CNA D said:
-He/she had not seen any activities being done with the residents on the hall.
-He/she had not seen any one on one activities being done with the residents.
-Bath Aide/CNA C would get pulled to work the floor instead of giving residents showers.
-He/she was the only CNA for about 20 residents today.
-He/she was able to get things done for the residents but it was right on the line to get the residents care done.
-Sometimes, the nurses would help out on the floor with the residents but not always.
-He/she had tried to express his/her concerns related to staffing.
-He/she was told by the Director of Nursing (DON) staffing was always going to be an issue.
During an interview on 10/23/20 at 1:08 P.M. Bath Aide/CNA C said:
-He/she was pulled to work the floor on the front hall.
-He/she was not doing showers today for the residents.
-There were no notes on the facility staffing sheet showing the staff member was pulled to work the floor instead of giving residents showers.
During an interview on 10/26/20 at 10:19 A.M., the MDS Coordinator said:
-He/she was the only MDS Coordinator.
-He/she would work the floor at night to cover staffing needs.
-He/she was now getting pulled two nights a week to work the floor and cannot fully concentrate on MDSs and care planning needs for the residents.
During an interview on 10/27/20 at 9:38 A.M., LPN B said:
-The facility only had one bath aide right now.
-The bath aide would get pulled to work on the floor instead of doing baths.
During an interview on 10/27/20 at 10:08 A.M., LPN A said:
-The bath aide got pulled to the floor to work quite often.
-The Activity Director did get pulled to work on the floor instead of completing activities.
-The Activity Director worked the evening shift as a CMT quite often since July 2020 and would also work on the weekends.
During the quality assurance interview on 10/27/20 at 10:54 A.M. the Administrator and Regional Nurse Consultant (previously the interim DON) said:
-Staffing was an issue and was brought up often.
-The Activity Director was pulled from resident activities to work the floor on average three times a month.
-Bath Aide/CNA C was pulled from completing resident baths to work the floor on average two times per week.
-The DON was pulled from his/her DON duties to work the floor as a charge nurse on average three days per week.
-The MDS Coordinator was pulled to work the floor as a charge nurse on average two days a week.
During an interview on 10/27/20 at 12:16 P.M. the ADON, the DON, and the Regional Nurse Consultant (previously the interim DON) said:
-DON:
--He/she was unsure how much time the Activity Director spent working on the floor as a CMT versus completing activities for the residents.
--He/she was aware only one bath was getting done per resident.
--If a resident looked like they needed a bath, he/she would have a staff member give the resident a bath.
--The facility was working on getting another bath aide because one bath aide cannot do 140 baths a week.
--He/she worked the floor as a charge nurse maybe twice a week.
--He/she worked the 40 hours and did the floor work.
--If he/she worked the medication cart in the morning, he/she stayed late to fulfill the DON duties.
--He/she was not sure if the Activity Director worked the floor versus doing activities with the residents.
--The bath aide did get pulled to work the floor instead of giving baths but could not give an average on how often.
--The MDS Coordinator worked an extra two nights a week on the floor.
--He/she did not have access to time sheets.
--If a staff member called in, a management staff member would stay and work that shift.
--A staff member should be assigned Monday through Friday to complete showers for the residents.
--A staff member should be assigned Monday through Friday to complete restorative nursing services for the residents.
--He/she did not know who or if audits were being conducted on resident showers or on resident restorative nursing services.
--If the restorative nursing staff member was pulled to work on the floor, he/she would try to work in some restorative nursing with the residents as he/she worked on the floor.
-Regional Nurse Consultant:
--There was one activity staff member for the building.
--If the MDS Coordinator worked overnights he/she would not be here during the week. He/she worked on the weekends.
--The Activity Director worked as a CMT on the evening but worked on resident activities during the day.
During a telephone interview on 10/27/20 at 4:28 P.M., Registered Nurse (RN) A, also the staffing coordinator said:
-If a charge nurse called in, he/she would try to replace the charge nurse with another nurse.
-If no one was available, he/she was required to cover the shift.
-If there was a hole in the schedule for CNA's, the management staff members would have the bath aide and/or restorative nursing work on the floor with the residents.
-He/she was unsure how resident baths or restorative services would be completed for the residents on the days these staff members were assigned to work on the floor.
-The MDS Coordinator worked on the floor as a charge nurse one to two days every ten days.
A staffing policy was requested and not received by the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure the Director of Nursing (DON) was serving as a DON only when the facility had an average occupancy of fewer than 60 res...
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Based on observation, interview and record review, the facility failed to ensure the Director of Nursing (DON) was serving as a DON only when the facility had an average occupancy of fewer than 60 residents. The facility census was 68 residents.
1. Record review of the facility's Census Report dated 10/19/20 showed the facility census was 68 residents.
Record review of the facility's Resident Census and Condition of Residents report dated 10/19/20 showed the facility census was 68 residents.
During an interview on 10/26/20 at 12:59 P.M. the DON said he/she was the charge nurse today for the unit.
Observation on 10/26/20 at 1:06 P.M. showed the DON was passing medications to the residents on the 500 hall.
During an interview on 10/26/20 at 2:36 P.M. the DON said he/she started acting as a charge nurse on the 500 hall unit at 12:00 P.M.
Observation on 10/26/20 at 2:37 P.M. showed the DON was passing medications to the residents on the 500 hall.
During an interview on 10/27/20 at 10:54 A.M. the Administrator and the Regional Nurse Consultant (previously the interim DON) said the DON was pulled to work the floor as a charge nurse on average three days per week.
During an interview on 10/27/20 at 12:16 P.M., the DON said:
-He/she worked the floor maybe twice a week.
-He/she worked the 40 hours acting as a DON and did the floor work acting as a charge nurse.
-If he/she worked the medication cart in the morning, he/she stayed late to fulfill the DON duties.
During a telephone interview on 10/27/20 at 4:28 P.M., Registered Nurse (RN) A, also the staffing coordinator said the DON worked on the floor as a charge nurse two to three days per week.
A policy was requested and not received by the facility.
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 observation, interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facili...
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Based on observation, interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 68 residents.
Record review of the facility's Inventory Control of Controlled Substances dated 12/1/07 and revised on 1/1/13 showed:
-The facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances (narcotics) and other medications with a risk of abuse or diversion at the change of every shift or at least once daily and document the results on the Controlled Substance Count Verification/Shift Count Sheet.
-The facility should ensure that staff count all Schedule III - V controlled substances in accordance with facility policy and applicable law.
1. Record review of the facility's Controlled Drug Count sheet dated 5/15/20 - 6/6/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-17 out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (6/5/20 day shift) was completely missing from the count sheet log.
-A total of 19 out of 44 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK 41 out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 5/26/20 - 6/8/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-19 out of 27 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (6/5/20 day shift) was completely missing from the count sheet log.
-A total of 21 out of 27 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK 27 out of 27 times.
Record review of the facility's Controlled Drug Count sheet dated 6/6/20 - 6/28/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Five out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (6/25/20 day shift) was completely missing from the count sheet log.
-A total of seven out of 44 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK 43 out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 6/9/20 - 6/30/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Seven out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK 18 out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 6/16/20 - 7/8/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Eight out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Two shifts (7/3/20 night shift and 7/4/20 night shift) were completely missing from the count sheet log.
-A total of 12 out of 44 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK 44 out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 6/29/20 - 7/18/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-13 out of 42 opportunities were not signed by either the oncoming or offgoing staff.
-7/16/20 day and night shift was documented as being counted twice (a total of four entries for 7/16/20).
-A total of 13 out of 42 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK 41 out of 42 times.
Record review of the facility's Controlled Drug Count sheet dated 7/1/20 - 7/21/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Five out of 43 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (7/5/20 day shift) was completely missing from the count sheet log.
-A total of 13 out of 42 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff checked the box yes under the heading Count OK 44 out of 43 times (staff had checked yes on a blank line without a date or signature).
Record review of the facility's Controlled Drug Count sheet dated 7/9/20 - 7/30/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-17 out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK 44 out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 7/18/20 - 8/8/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-17 out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK 34 out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 7/22/20 - 8/12/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Two out of 43 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (7/31/20 night shift) was completely missing from the count sheet log.
-A total of four out of 43 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff checked the box yes under the heading Count OK 43 out of 43 times.
Record review of the facility's Controlled Drug Count sheet dated 7/31/20 - 8/21/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Eight out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK eight out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 8/9/20 - 8/30/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Seven out of 42 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (8/14/20 day shift) was completely missing from the count sheet log.
-A total of nine out of 42 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK eight out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 8/13/20 - 9/2/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Five out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK one out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 8/21/20 - 9/12/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Five out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (8/30/20 day shift) was completely missing from the count sheet log.
-A total of seven out of 44 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK two out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 8/30/20 - 9/20/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Seven out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK eight out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 9/3/20 - 9/18/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-One out of 32 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK four out of 32 times.
Record review of the facility's Controlled Drug Count sheet dated 9/12/20 - 9/29/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-Ten out of 35 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK six out of 35 times.
Record review of the facility's Controlled Drug Count sheet dated 9/17/20 - 10/7/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-15 out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK 15 out of 44 times.
Record review of the facility's 100 Hall Controlled Drug Count sheets dated 9/20/20 - 10/22/20 showed:
-13 out of 64 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (9/30/20 night shift) was completely missing from the count sheet log.
-A total of 15 out of 66 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK seven out of 64 times.
Record review of the facility's 300/400 Hall Controlled Drug Count sheets dated 9/20/20 - 10/22/20 showed:
-15 out of 64 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (9/30/20 night shift) was completely missing from the count sheet log.
-A total of 17 out of 66 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK six out of 64 times.
Record review of the facility's Controlled Drug Count sheet dated 9/21/20 - 10/9/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-17 out of 36 opportunities were not signed by either the oncoming or offgoing staff.
-One shift (9/30/20 night shift) was completely missing from the count sheet log.
-A total of 19 out of 36 opportunities did not have staff documentation the shift change narcotic counts were completed.
-Staff did not check the box yes or no under the heading Count OK ten out of 36 times.
Record review of the facility's Controlled Drug Count sheet dated 10/2/20 - 10/22/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-27 out of 44 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK 33 out of 44 times.
Record review of the facility's Controlled Drug Count sheet dated 10/7/20 -10/22/20 showed:
-The document did not identify which hall the narcotic count sheet was for.
-16 out of 30 opportunities were not signed by either the oncoming or offgoing staff.
-Staff did not check the box yes or no under the heading Count OK 25 out of 30 times.
Observation on 10/21/20 at 6:15 A.M. showed:
-Licensed Practical Nurse (LPN) C and LPN A were completing the shift change narcotic count on the 100/200/300/400 nurse's medication cart.
-LPN C called out a number while LPN A flipped through the medication cards and said yes after each number was called.
-Neither LPN C nor LPN A confirmed the name of the medication or the resident name during the shift change narcotic count.
During an interview on 10/21/20 at 6:45 A.M., LPN A said:
-The nurses count the narcotics on the medication cart and medication room each shift.
-The oncoming nurse and the offgoing nurse should sign the Controlled Drug Count sheet after they have completed the narcotic count.
During an interview on 10/27/20 at 1:59 P.M., the Director of Nursing (DON) said:
-He/She expected the offgoing nurse and oncoming nurse to count the narcotics on the medication cart and in the medication room each shift.
-He/She expected staff to sign on the Controlled Drug Count sheet the narcotic count was completed,
-At this time, no one is auditing the narcotic count sheets to ensure the shift change count was being completed by staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the medication refrigerator temperatures were monitored and maintained within appropriate limits; to ensure insulins a...
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Based on observation, interview, and record review, the facility failed to ensure the medication refrigerator temperatures were monitored and maintained within appropriate limits; to ensure insulins and eye drops were dated when they were opened and to ensure expired medications were removed from the medication delivery system in two medication carts and one medication room. The facility census was 68 residents.
Record review of the facility's Pharmacy Services and Procedures Manual - Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated 12/1/07 and revised on 10/28/19 showed:
-Facility should ensure that medications and biologicals that have an expired date on the label are stored separately from other medications until destroyed or returned to the pharmacy or supplier.
-Facility should ensure that food is not to be stored in the refrigerator or general storage areas where medications and biologicals are stored.
-Once a medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications.
-Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened.
-If a multidose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specified a different (longer or shorter) date for that opened vial.
-When ophthalmic (eye) solutions or suspensions are opened, the bottle should be dated and discarded within 28 days unless the manufacturer specified a different (longer or shorter) date for that opened bottle.
-Facility should ensure all medications and biologicals requiring special containers for stability in accordance with manufacturer/supplier specifications.
-Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Facility staff should monitor the temperatures of vaccines twice a day.
-Refrigeration temperatures should be between 36 degrees Fahrenheit (F) to 46 degrees F.
-Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other applicable law.
-Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.
1. Observation of the 100-400 hall Certified Medication Technician (CMT) medication cart on 10/21/20 at 5:45 A.M. showed a half-empty bottle of Tylenol (an over-the-counter pain reliever) with an expiation date of 8/20 was marked as opened for resident use on 9/3/20. This was after the medication was expired.
Observation of the 100-400 hall Medication Room on 10/21/20 at 5:59 A.M. showed:
-An unopened Lunchable and an opened Pepsi bottle in the medication refrigerator with resident medications.
-Two opened vials of Aplisol (also known as purified protein derivative, is a combination of proteins that are used in the diagnosis of tuberculosis [TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function]) in one box with no date on the vials when they were opened.
-An empty box used to contain wine coolers (an alcoholic beverage).
-A refrigerator temperature monitoring sheet taped to the outside of the medication refrigerator door dated June 2020. The temperature had been documented 10 out of 30 opportunities.
-A refrigerator temperature monitoring sheet taped to the outside of the narcotic medication refrigerator door dated June 2020. The temperature had been documented 10 out of 30 opportunities. The temperature was below 36 degrees F 10 out of 10 times it was documented that month.
-Two opened, undated bottles of Ativan in the narcotic medication refrigerator.
During an interview on 10/21/20 at 6:15 A.M., Licensed Practical Nurse (LPN) C said:
-He/She was not certain who checked the temperatures of the refrigerators.
-He/She did not know when the Ativan bottles were opened or why they were in one box.
-Opened food or beverages should not be stored in the medication refrigerators.
During an interview on 10/21/20 at 7:03 A.M., LPN A said he/she thought the night shift checked and documented the medication refrigerator temperatures.
During an interview on 10/21/20 at 7:05 A.M., the Director of Nursing (DON) said:
-He/She expected staff to check and document the medication refrigerator temperatures at least daily.
-He/She did not know when the refrigerator temperatures had been checked last.
-At that time, no one was responsible to audit to ensure the refrigerator temperatures were completed.
-He/She expected staff to check the medication carts, medication rooms, and medication refrigerators at least weekly for expired medications.
-Any expired medications should be removed from the medication delivery system and sent to the pharmacy to be destroyed.
-Staff should not open a bottle of medication that had expired to use after the expiration date.
-Staff should not administer expired medications.
Observation on 10/21/20 at 7:10 A.M. of the 500 hall nurse's medication cart showed:
-An opened, undated vial of Cosopt (prescription eye drop).
-An opened vial of Cosopt dated 8/9/20.
-Two opened, undated vials of Travatan (a prescription eye drop).
-An Albuterol metered dose inhaler without a box, resident's name, or date it was opened in the medication cart drawer.
-An opened, undated vial of Asopt (prescription eye drop).
-A bottle of Fireball whiskey without a resident's name or label.
-An opened, half-filled bottle of Zinc 220 milligrams (mg) with an expiration date of 8/19.
-An opened, undated vial of Lantus (a long acting insulin).
-An opened, undated vial of Novolog (a short acting insulin).
-An opened undated vial of Levemir (a long acting insulin).
During an interview on 10/21/20 at 7:15 A.M., LPN D said:
-The medication cart should not have expired medications in them.
-Any opened vials or bottles should have the date the medication was opened.
-The Fireball whiskey was for a resident, but he/she did not know which one.
-Medication carts are checked at least weekly for expired medications.
During an interview on 10/27/20 at 1:53 P.M., the DON said:
-He/She expected staff to date vials and bottles of medications when the medication is opened.
-He/She expected the Albuterol would be stored in the box it was received in and labeled with the resident's name. It should not have been unlabeled and stored without the box in the medication cart.
-He/She expected either the CMT or nurse to check the medication carts at least weekly for expired medications.
-He/She expected expired medications to be removed from the medication carts and not administered to the residents.
-Food and/or beverages should not be stored with medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain sanitary food serving utensils; to ensure plastic cutting boards were in good condition to avoid food safety hazards...
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Based on observation, interview, and record review, the facility failed to maintain sanitary food serving utensils; to ensure plastic cutting boards were in good condition to avoid food safety hazards; and to refrigerate open foodstuffs that stated to do so on their labels. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 68 residents with a licensed capacity for 90.
1. Observations during the kitchen inspection on 10/19/20 between 8:57 A.M. and 11:43 A.M. showed the following:
-An open 1-gallon jug of Teriyaki sauce approximately 3/5 full located on the upper shelf of a rack in the dry storage stated Refrigerate After Opening on the label.
-One red and one green cutting board on a lower shelf under a microwave both were heavily scored to the point of plastic bits hanging off them.
-An open 1-gallon jug of soy sauce approximately 1/4 full located on the bottom shelf of a cart by the 3-sink area stated Refrigerate After Opening for Quality on the label.
-A blue handled scoop in a plastic 3-drawer cart under a food preparation table had its handle pitted and worn to the point of plastic bits hanging off it.
During an interview on 10/22/20 at 9:27 A.M., the Dietary Manager (DM) said the following:
-The DM checks the cutting boards daily and if found overly damaged the Dietician is consulted on their disposal.
-The cutting boards are replaced roughly every six months.
-The DM checks the food serving utensils daily for damage and wear.
-If the labels on foodstuffs state to refrigerate after opening, he/she expected that guideline to be followed.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed:
-Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
-In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to complete a Facility Assessment to determine resources necessary to meet the needs of the residents, such as assessment of the resident popu...
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Based on interview and record review, the facility failed to complete a Facility Assessment to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community-based risk assessment. A total of 17 residents were sampled. The facility census was 68 residents.
1. Record review of the facility's Facility Assessment, dated 9/9/20, showed:
-There was no documentation that showed the residents' diseases, conditions, physical and cognitive disabilities or the facility acuity level.
-The facility did not vary staffing levels according to a prospective resident's acuity or care needs.
-Staffing:
--Current staffing was stable from day to day and shift to shift based on normal and expected care needs of the residents.
--When residents with extensive care needs are considered for admission, the administrator, admissions director, and Director of Nursing (DON) determine whether additional staffing was required or whether the admission should be refused.
--In other words, the facility did not vary staffing levels according to a prospective residents' acuity or care needs.
--Instead, we admit or refuse to admit residents based on our estimation of whether we can meet their care needs with the existing staffing model.
-Staff training and competency:
--The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care.
--The facility conducted competency reviews upon initial employment and annually thereafter through skills check offs and return demonstration.
--The general competencies were not listed.
--Competencies for Wound Vacuum Assisted Closure (Wound V.A.C. - negative pressure wound therapy, a type of therapy to help wound healing by decreasing air pressure around the wound with a vacuum pump which pulls fluid and infection from a wound) were not listed.
-The report was signed by the Administrator, the Medical Director, and the DON.
During the quality assurance interview on 10/27/20 at 10:54 A.M. the Administrator and Regional Nurse Consultant (previously the interim DON) said:
-During the last quality assurance meeting included the Medical Director, Administrator, DON, ADON and all department management.
-The facility assessment was updated quarterly and as needed.
-Resident acuity was not used to determine staffing.
-The level of care needs for the residents were not listed in the facility assessment.
During an interview on 10/27/20 at 12:16 P.M. the ADON, the DON, and the Regional Nurse Consultant (previously the interim DON) said:
-He/she looked at the resident's clinical condition to see if the facility was able to meet their needs before admission.
-This was how he/she determined the staffing needs.
--Everyone here should be able to provide basic cares.
--Upon hire, the new employee went through basic care training.
-He/she discussed wound VACs with the nurse but he/she did not develop a competency.
-He/she would tell the nurse what to do with the Wound VAC.
The Facility Assessment policy was requested, but not received by the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure infection control procedures were followed to p...
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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 infection control procedures were followed to prevent cross-contamination by not performing appropriate hand hygiene (wash or sanitize hands) between glove changes, during incontinent care and during urinary catheter (a tube passed through the urethra into the bladder to drain urine) care for two sampled residents (Resident #31 and #62), during wound care for two sampled residents (Resident #34 and #62), during blood glucose monitoring for one sampled resident (Resident #13) and two supplemental residents (Residents #46 and #67), and not sanitizing the blood glucometer (a machine to measure blood sugar levels) between residents for one sampled resident (Resident #13) and two supplemental residents (Resident #46 and #67), not ensuring isolation precautions were maintained for newly admitted residents for one sampled residents (Resident #31), failed to ensure one sampled resident's (Resident #62) linens were properly handled, failed to ensure scissors were sanitized prior to use during one sampled resident's (Resident #62) wound care, and failed to ensure a tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) test or screening was completed for two sampled residents (Resident #13 and #62) out of 17 sampled residents and to supplemental residents. The facility census was 68 residents.
Record review of the facility's Wound Vacuum Assisted Closure (Wound V.A.C. - negative pressure wound therapy, a type of therapy to help wound healing by decreasing air pressure around the wound with a vacuum pump which pulls fluid and infection from a wound) policy, dated 11/1/06 and revised on 1/15/10 ,did not direct staff when to change gloves and wash hands during the wound vac dressing change.
Record review of the facility's Glucose Monitoring Equipment - Care, Cleaning, Disinfecting, and Quality Control Testing policy, dated 2/1/08 and updated on 4/30/10, showed Infection Control measures should be done according to Centers for Disease Control and Prevention (CDC), State, and Federal requirements.
Record review of the facility's Urinary Catheter Care, policy, dated 11/10/14, showed:
-Urinary Catheter care helps to prevent Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system).
-Wash hands thoroughly before and after providing catheter care; wear gloves.
-Wash the perineal area (genital area) per policy.
-Wash the catheter itself by holding on to the catheter at the insertion site; wash with one stroke downward approximately three inches from the insertion site while holding the catheter to prevent pulling. Repeat as needed.
Record review of the facility's Tuberculosis (TB) Screening policy, dated 12/1/09 and revised on 11/14/16, showed:
-Residents are required to have a negative chest X-ray, no longer than 30 days prior to admission to the facility.
-Upon admission, residents should receive the Purified Protein Derivative (PPD - a method used to diagnose silent (latent) tuberculosis (TB) infection) two-step screening. If screening was done by the transferring hospital, it must have occurred within 30 days prior to nursing home admission. The facility should obtain document the results of the X-rays and PPD results.
-Residents may receive an annual PPD test within one week of the admission anniversary date.
-Perform the two-step PPD screening on admission if documentation of a test within the past 30 days was not received on admission.
-Apply first test and read in 72 hours. If the results are negative (0-9 millimeters (mm) of induration) apply second test 1-3 weeks later. Read the results of the second test in 72 hours.
-Results of all PPD tests and X-rays should be documented in the resident's medical record.
Record review of the facility's Blood Glucose Testing policy, dated 4/15/10 and revised on 10/1/19, showed:
-Meter care: store meter in carrying case.
-Blood Glucose/PT/INR Machine Cleaning Guidelines:
--Prepare two surfaces, one for clean items and one for contaminated, impermeable barrier must be used.
--Place bleach germicidal sporicidal disinfectant wipe on clean surface with a pair of clean gloves.
--Don (put on) first pair of gloves, do procedure, place glucometer on contaminated surface, impermeable barrier must be used.
--Wash hands and put on second pair of gloves.
--Clean glucometer with bleach germicidal sporicidal disinfectant wipe, place on clean impermeable barrier, air dry per manufacturer's recommendations. When visibly soiled two wipes will be needed, one for soiling and one for disinfecting afterwards.
--Place all gloves and contaminated cleaning equipment in bag and remove from room, place lancet in sharps container,
--Wash hands and take glucometer from room.
--Disinfectant wipes should be stored in the medication cart separate from the medications (i.e. in a separate basket).
Record review of the facility's Hand Hygiene policy, dated 3/13/20 and updated on 6/11/20, showed:
-Handwashing should be performed between procedures with a resident based upon the principle that all blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes may contain transmissible infectious agents.
-Hand sanitizer may be applied to the hands between tasks if hands were not visibly soiled.
-Staff should perform hand hygiene before and after performing invasive procedures (such as fingerstick blood sampling).
-Before and after entering isolation precautions settings.
-Before and after assisting the resident with personal care.
-Before and after changing a dressing.
-Upon and after coming in contact with a resident's intact skin.
-After contact with a resident's mucous membranes and body fluids or secretions.
-After handling soiled or used linens, dressings, and catheters.
-After removing gloves.
-Before or after contact with a known or suspected COVID (a new disease caused by a novel (new) coronavirus) resident.
1. Record review of Supplemental Resident #46's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
Record review of the resident's Physician's Order Sheet (POS,) dated October 2020, showed:
-Glucogon (a medication to raise blood glucose levels) 1 milligram (mg) give intramuscularly (in the muscle) as needed for blood glucose less than 70 and the resident is not responsive.
-Novolog (a fast acting insulin) give 3 units daily subcutaneously (under the skin) three times daily with meals, hold for blood glucose less than 150.
-Lantus (a long acting insulin) give 5 units daily at bedtime.
-No documentation for an order to check the resident's blood glucose level or how often to check the resident's blood glucose level.
Observation on 10/21/20 at 7:43 A.M., showed:
-A glucometer on top of the medication cart wrapped in a disinfectant wipe.
-Licensed Practical Nurse (LPN) A removed a clear plastic bag from the medication cart and removed a glucometer from the plastic bag.
-Without sanitizing the glucometer, he/she placed the glucometer in a styrofoam container with the rest of the blood glucose monitoring supplies.
-LPN A performed hand hygiene and obtained the resident's blood glucose sample.
-He/She removed his/her gloves, washed his/her hands, and with bare hands, put the contaminated meter back in the container,
-He/She then gloved, sanitized the glucometer with disinfectant wipes that were placed in the container before entering the room, and exited the resident's room with gloved hands carrying the glucometer in his/her gloved hands.
-He/She then unwrapped the glucometer and placed it on top of the medication cart without a barrier.
-He/She removed his/her gloves, sanitized his/her hands, then picked up the contaminated glucometer and placed it in a new container.
2. Record review of Supplemental Resident #67's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of diabetes.
Record review of the resident's Physician's Order Sheet (POS) dated October 2020 showed he/she was to have blood glucose check with meals and before bedtime for diabetes.
Observation on 10/21/20 at 7:47 A.M., showed:
-LPN A entered the resident's room and donned (applied) clean gloves without washing or sanitizing his/her hands.
-He/She removed the contaminated glucometer from the barrier container, obtained the resident's blood glucose sample and placed the contaminated meter back in the barrier container.
-He/She removed his/her gloves, washed his/her hands, donned clean gloves and wrapped the glucometer in a sanitizing wipe that was stored in the barrier container.
-He/She exited the resident's room with gloved hands, unwrapped the glucometer, and placed the glucometer on top of the contaminated medication cart without a barrier.
3. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of diabetes.
Record review of the resident's POS, dated October 2020, showed he/she was to have blood glucose checks with meals and before bedtime for diabetes.
Observation on 10/21/20 at 7:53 A.M., showed:
-LPN A unwrapped the disinfecting wipe from a sanitized glucometer that was on top of the medication cart and placed it in the barrier container and sanitized his/her hands.
-LPN A then pushed his/her medication cart to the locked unit, pushed the button on the wall to enter the doors and entered the locked unit.
-He/She knocked on the resident's door, entered the resident's room, and donned clean gloves without washing or sanitizing his/her hands.
-He/She obtained the resident's blood glucose sample, placed the contaminated glucometer in the barrier container, removed his/her gloves and washed his/her hands.
-He/She donned clean gloves, wrapped the glucometer in sanitizing wipes from the barrier container.
-He/She removed one glove, and without washing or sanitizing his/her hands, touched the doorknob, opened the resident's door and exited the resident's room with gloves on one hand and one bare hand.
-He/She placed the glucometer on top of the medication cart wrapped in a sanitizing wipe next to an unwrapped glucometer that was on top of the medication cart not on a barrier.
During an interview on 10/27/20 at 9:49 A.M., LPN A said:
-He/She should have sanitized his/her hands after entering the resident's room, before donning gloves, and after removing gloves.
-Glucometers should be kept on a barrier and sanitized between residents.
During an interview on 10/27/20 at 1:58 P.M., the Director of Nursing (DON) said:
-He/She expected staff to sanitize the glucometer if they were unsure if it was sanitized before using it.
-Glucometers should be sanitized before putting in the plastic bag for storage.
-Staff should use a barrier if placing the glucometer on top of the medication cart.
-Staff should wash or sanitize their hands upon entering a resident's room, before donning gloves, after removing gloves, and between residents.
-He/She expected staff to ensure the glucometer was sanitized after use and between resident use.
3b. Record review of the resident's April 2020 POS showed:
-No documentation by the facility staff the first step TB skin test was administered or read.
-No documentation by the facility staff a second step TB skin test was administered or read.
During an interview on 10/22/20 at 8:30 A.M., the Administrator said he/she could not find documentation a TB skin test was administered or read after the resident was admitted to the facility.
4. Record review of Resident #62's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Cellulitis (an infection of deep skin tissue).
-Methicillin Resistant Staphylococcus Aureus (MRSA - a type of bacteria that is resistant to many antibiotics).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-Localized edema (swelling).
-Pressure Ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) Stage III (a full thickness tissue loss. Subcutaneous (under the skin). fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue). may be present but does not obscure the depth of tissue loss. May include undermining or tunneling).
-Herpes Zoster (shingles - A reactivation of the chickenpox virus in the body, causing a painful rash that may appear as a stripe of blisters on the trunk of the body. Pain can persist even after the rash is gone) with other complications.
Record review of the resident's October 2020 POS showed:
-A first step TB skin test was administered on 10/5/20.
-No documentation by the facility staff the first step TB skin test was read.
-No documentation by the facility staff a second step TB skin test was administered or read.
During an interview on 10/27/20 at 12:44 P.M., the DON said:
-The resident's TB skin test should be administered by the nurse.
-There should be an order to administer and to read the TB skin test on the resident's POS and Medication Administration Record (MAR).
-The first step TB skin test should be administered within 24 hours of admission to the facility.
During an interview on 10/27/20 at 1:40 P.M., LPN A said:
-The charge nurse should administer the TB skin test on all new admissions within a week of the resident being admitted to the facility.
-He/She would document the TB skin test administration and that it was read on the resident's MAR.
4b. Record review of the resident's October 2020 POS showed:
-Stage III pressure ulcer to the coccyx (tailbone) - treat every Tuesday and Friday and as needed (PRN). Cleanse with wound cleanser, apply non-sting barrier to periwound (area of skin around the outer edges of the wound). Protect with tegaderm hydrocolloid thin (a wound dressing).
-Negative Pressure wound treatment (wound vac) to be applied to the left lower back and left lateral back set at 125 millimeters (mm). The dressing should be changed every Monday, Wednesday, and Friday and as needed - check every shift.
Observation on 10/22/20 at 9:42 A.M., showed:
-Certified Nursing Assistant (CNA) E was making the resident's bed and put the dirty linens on the floor.
-The DON donned a gown and gloves without washing or sanitizing his/her hands and entered the resident's room.
-The DON disconnected the resident's wound vac tubing and placed one end in an alcohol wipe pad package.
-After assisting Certified Nursing Assistant (CNA) E transfer the resident from the wheelchair to the bed, the DON removed the gait bed from the resident's waist, and picked up the wound vac and put it up on the resident's nightstand.
-The DON removed his/her gloves, adjusted the resident's bed, pulled up the floor mattress on the left side of the resident's bed without sanitizing his/her hands.
-The DON left the room with a bottle of hand sanitizer, but did not sanitize his/her hands until he/she reached the nurse's station desk.
Observation on 10/22/20 at 10:02 A.M. showed:
-The DON entered the resident's room, stepped over the dirty linens which were still on the floor from when CNA E made the resident's bed, and donned clean gloves without sanitizing his/her hands.
-The Assistant Director of Nursing (ADON) donned clean gloves without washing or sanitizing his/her hands.
-The DON and ADON put a drawsheet under the resident, each taking turns pushing/pulling the drawsheet under the resident while the other assisted with turning the resident in bed.
-The DON pulled the curtain closed, then with the same gloved hands, removed the resident's wound vac dressing from his/her left lateral back and mid-back non-pressure wounds.
-With the same contaminated gloves, the DON touched the resident's privacy curtain, removed his/her gloves, exited the room, and opened up the drawers to the wound treatment cart with contaminated ungloved hands.
-He/She then sanitized his/her hands and continued looking through drawers for supplies.
-He/She placed the wound care supplies, including a pair of scissors that he/she removed from the treatment cart drawers, in a barrier container.
-The DON re-entered the resident's room and donned new gloves without sanitizing his/her hands.
-The DON sprayed wound cleanser to the resident's left lateral back wound, and with scissors that had not been sanitized, cut a hole in the transparent dressing and placed the transparent dressing over the resident's wound so the hole lined up with the wound bed.
-With the same unsanitized scissors, the DON cut the black sponge and placed the black sponge on the resident's left lateral wound bed.
-With the same unsanitized scissors, the DON cut additional transparent dressing tap and placed it over the wound and sponge.
-With the same contaminated gloves, the DON assisted the resident to adjust in the bed and adjusted the resident's bed.
-He/She removed his/her gloves, sanitized his/her hands, and sprayed wound cleanser to the resident's mid-back non-pressure wound.
-With the same unsanitized scissors, the DON cut a hole in the transparent dressing and covered the resident's mid-back wound so the hole lined up over the resident's woundbed.
-With the same gloved hand, he/she cut more transparent dressing, placed the dressing on the resident's back between the two woundbeds.
-With his/her gloved hands, he/she pushed off from the center of the resident's bed to stand up, placing the scissors on the resident's bed.
-He/She then picked up the scissors and cut more black sponge to make a bridge between the two woundbeds and to cover the mid-back wound.
-The resident was calling out he/she was having difficulty breathing, so the DON and ADON assisted the resident to sit up on the side of the bed.
-With the same contaminated gloved hands, the DON applied the black sponge to the resident's mid-back wound and applied the transparent dressing over the sponge.
-With the same contaminated gloved hands and contaminated scissors, the DON cut a sliver hole in the transparent dressing over the black sponge bridge and applied the wound vac suction tubing.
-The DON removed his/her gloves, sanitized his/her hands, put the trash from the dressing change in a bag, removed his/her gloves, sanitized his/her hands, and opened the resident's door.
-He/She opened drawers in the wound treatment cart, removed additional transparent dressings, re-entered the resident's room and donned clean gloves without washing or sanitizing his/her hands.
-He/She applied two additional clear dressings to the resident's wound vac, changed the canister for the wound vac, and attached the tubing from the wound to the wound vac.
-Both the DON and ADON removed their gloves, sanitized their hands and left the resident's room.
During an observation on 10/22/20 at 2:11 P.M., showed:
-The DON sanitized his/her hands, donned clean gloves, then touched the resident's privacy curtains to open the curtains, went to the resident's open door and called out for a nurse for pain medications for the resident.
-He/She came back into the resident's room, touched the curtains with the same gloves, then the resident's wound vac tubing.
-He/She started to pull down the resident's briefs, but noticed the resident had been incontinent of stool.
-He/She pulled the resident's shirt down and pants up, and with the same gloves, opened the resident's privacy curtain, opened the resident's nightstand and dresser drawers, then opened the bathroom door, then went to resident's door.
-He/She came back to the resident's bedside, touched the resident's privacy curtain, then pulled down the resident's pants and unfastened his/her brief.
-The resident did not have a dressing on his/her coccyx wound.
-He/She started to clean the resident's buttock, then removed his/her gloves, sanitized his/her hands, and donned clean gloves.
-He/She pulled the resident's pants down some more, then opened the curtain slightly, went to the resident's door and called out to get additional staff.
-CNA E entered the room, donned gloves without washing or sanitizing his/her hands.
-The DON continued to clean additional incontinent stool from the resident's buttocks.
-He/She removed his/her gloves and donned clean gloves without washing or sanitizing his/her hands.
-He/She then walked to the resident's bathroom, removed his/her gloves, and without washing or sanitizing his/her hands, opened the bathroom door, then left the resident's room without washing or sanitizing his/her hands.
-He/She returned to the resident's room, sanitized his/her hands and donned clean gloves.
-CNA E removed his/her gloves then donned clean gloves without washing or sanitizing his/her hands.
-The DON cleansed the resident's coccyx wound with normal saline.
-He/She opened a package of skin prep applied skin prep around the wound edges with the same contaminated gloved hands.
-With the same contaminated gloved hands, he/she applied the new dressing to the resident's coccyx wound.
-With the same gloved hands, the DON and CNA E finished putting a clean brief on the resident.
-Both the DON and CNA E removed their gloves and sanitized their hands before leaving the resident's room.
During an interview on 10/27/20 at 1:22 P.M., the DON said:
-Staff should not put soiled or dirty linens on the floor. He/She stepped over the soiled or dirty linens when he/she entered the resident's room and did not pick them up either.
-He/She should have sanitized the scissors before using them to cut the dressing and sponge.
-Wound treatment supplies should not have been placed on the bed.
-He/She should have sanitized his/her hands after removing his/her gloves and before donning clean gloves.
-Staff should not touch the resident or the resident's environment with contaminated gloves.
-Staff should sanitize their hands when entering a resident's room and before leaving the resident's room.
-He/She should have changed his/her gloves after performing wound care before applying the new dressings.
5. Record review of Resident #31's Face Sheet showed he/she was admitted to the facility on [DATE] and was readmitted on [DATE].
Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 8/21/20, showed he/she:
-Was cognitively intact with a BIMS (brief interview for mental status) of 15 out of 15.
-Required extensive staff assistance for dressing and bathing.
-Required total staff assistance for toileting.
-Had a urinary catheter.
Record review of the resident's POS, dated 10/2020, showed the following physician's orders: Contact/droplet precautions from fourteen days from admission.
Observation on 10/19/20 between 8:30 A.M. - 3:30 P.M., showed:
-No isolation cart outside the resident's room.
-No isolation precaution signage outside the resident's room or on his/her door.
-Staff entered and exited the resident's room without Personal Protective Equipment (PPE - is equipment worn to minimize exposure to a variety of hazards. Examples of PPE include such items as gloves, facemasks or face shields, respirators, foot and eye protection, and gowns).
Observation and interview on 10/20/20 at 11:28 A.M., showed:
-An isolation cart outside the resident's room with a sign on the resident's door to see the nurse before entering the room.
-A small, red, basket with a red trash liner and covered by a lid by the resident's door.
-A larger cardboard box with a red trash liner that was uncovered by the resident's door.
-The resident said staff just started wearing PPE that day, he/she was not sure why, but thought it could have to do with him/her just returning from a stay at the hospital.
Observation on 10/21/20 from 7:14 A.M. - 12:00 P.M., on 10/22/20 from 8:30 A.M. - 3:00 P.M., on 10/23/20 from 8:30 A.M. - 2:30 P.M., on 10/26/20 from 8:10 A.M. - 2:00 P.M., and on 10/27/20 from 8:15 A.M. - 11:30 A.M. showed:
-An isolation cart outside the resident's room with a sign on the resident's door to see the nurse before entering the room.
-A small, red, basket with a red trash liner and covered by a lid by the resident's door.
-A larger cardboard box with a red trash liner that was uncovered by the resident's door.
During an interview on 10/27/20 at 9:26 A.M., CNA E said:
-The resident should have had an isolation cart and isolation bins in his/her room when he/she came back from the hospital.
-The small red basket with the lid is for contaminated linens.
-The larger cardboard box is for discarding gown and gloves before leaving the resident's room.
-He/She is not aware if both containers should be covered or not.
-There was not a lid for the cardboard box.
5b. During an observation on 10/22/20 at 11:35 A.M., showed:
-Nursing Assistant (NA) F and Restorative Aide (RA) A donned a gown and clean gloves, then entered the resident's room without sanitizing their hands.
-NA F removed the resident's blankets and began looking for the resident's briefs.
-NA F opened the resident's brief and cleansed the resident's front genital area, using one wipe for each swipe, touching the wipe package with contaminated gloved hands to obtain more wipes.
-With the same contaminated gloved hands, NA F and RA A assisted the resident to turn to his/her side.
-NA F picked up the resident's catheter bag and tubing prior to assisting the resident to turn to his/her side.
-NA F cleansed the resident's buttocks area, then with the same gloved hands, touched the resident's draw sheet and underpad.
-With the same contaminated gloved hands, NA F obtained a clean brief and assisted the resident to turn to his/her back.
-RA A removed his/her gloves and washed his/her hands while NA F continued to push the underpad under the resident and then put the dirty linens and brief on top of the resident's pillows at the end of the resident's bed.
-RA A donned clean gloves and applied protective cream to the resident's buttocks, then removed his/her gloves and washed his/her hands.
-NA F, with the same contaminated gloved hands, then touched the resident's suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) tubing and began to wipe it down with cleansing wipes.
-NA F, with contaminated gloved hands, and RA A then put a clean brief on the resident
-NA F put the old brief in the regular trash and put the contaminated wipes package on the resident's heating/cooling unit by the window.
-Both RA A and NA F removed their gloves and washed their hands.
-NA F then donned clean gloves, adjusted the resident's underpad, and put the pillows that had had the soiled linens and brief, under the resident for positioning.
-NA F then removed his/her gloves, and both RA A and NA F removed their isolation gowns, discarded them in the opened cardboard box without a lid and left the room.
-NA F exited the resident's room without sanitizing his/her hands.
During an interview on 10/26/20 at 1:16 P.M., NA F said:
-He/She should have changed his/her gloves after cleaning the resident's front genital area before cleaning the resident's buttocks.
-He/She should have changed his/her gloves after cleaning the resident's buttocks before cleaning the resident's catheter tubing,
-He/She should not have touched the wipe package with contaminated gloved hands.
-He/She should not have touched the resident or the resident's environment with contaminated gloved hands.
-He/She should have washed or sanitized his/her hands after removing gloves, before donning gloves, and before leaving the resident's room.
-The smaller can is for dirty linen, the larger cardboard box is for discarding gowns.
-He/She is unaware if the box should be covered or not.
6. During an interview on 10/26/20 at 1:44 P.M., LPN B said:
-Staff should wash or sanitize their hands before donning gloves, before providing cares, after removing gloves, and before leaving the resident's room.
-Staff should change their gloves when going from one area of the resident's body to another during care, including incontinence/catheter/wound care.
-Staff should not touch the resident or the resident's environment with contaminated gloved hands.
During an interview on 10/27/20 at 9:13 A.M., CNA E said:
-Staff should wash or sanitize their hands when entering a resident's room, before donning gloves, before providing cares, after removing gloves, and before leaving a resident's room.
-Staff should change their gloves and wash or sanitize their hands when going from one area to another during incontinence or catheter care.
-Staff should not clean a resident's buttocks then clean the resident's catheter tubing.
-Staff should not touch the resident or the resident's environment with contaminated gloved hands.
During an interview on 10/27/20 at 9:49 A.M., LPN A said:
-Staff should wash or sanitize their hands before donning gloves, before providing cares, after removing gloves, and before leaving the resident's room.
-Staff should change their gloves when going from one area of the resident's body to another during care, including incontinence/catheter/wound care.
-Staff should not touch the resident or the resident's environment with contaminated gloved hands.
During an interview on 10/27/20 at 12:59 P.M., the DON, Administrator, and Corporate Nurse said:
-Staff should wash or sanitize their hands before donning gloves, before providing cares, after removing gloves, and before leaving the resident's room.
-Staff should change their glove when going from one area of the resident's body to another during care, including incontinence/catheter/wound care.
-Staff should not touch the resident or the resident's environment with contaminated gloved hands.
-Resident #31's care should have included isolation on 10/18/20 when he/she returned from the hospital.
-When he/she noticed the resident was not on isolation, he/she had the isolation cart, signage, and supplies put outside his/her room.
-The isolation barrels (basket and cardboard box) should have a lid.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 59 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $14,433 in fines. Above average for Missouri. Some compliance problems on record.
- • Grade F (16/100). Below average facility with significant concerns.
Bottom line: Trust Score of 16/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Aspire Senior Living Pleasant Hill's CMS Rating?
CMS assigns ASPIRE SENIOR LIVING PLEASANT HILL 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 Aspire Senior Living Pleasant Hill Staffed?
CMS rates ASPIRE SENIOR LIVING PLEASANT HILL's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 86%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Aspire Senior Living Pleasant Hill?
State health inspectors documented 59 deficiencies at ASPIRE SENIOR LIVING PLEASANT HILL during 2020 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 57 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Aspire Senior Living Pleasant Hill?
ASPIRE SENIOR LIVING PLEASANT HILL is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ASPIRE SENIOR LIVING, a chain that manages multiple nursing homes. With 90 certified beds and approximately 80 residents (about 89% occupancy), it is a smaller facility located in PLEASANT HILL, Missouri.
How Does Aspire Senior Living Pleasant Hill Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, ASPIRE SENIOR LIVING PLEASANT HILL's overall rating (1 stars) is below the state average of 2.5, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Aspire Senior Living Pleasant Hill?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Aspire Senior Living Pleasant Hill Safe?
Based on CMS inspection data, ASPIRE SENIOR LIVING PLEASANT HILL has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Aspire Senior Living Pleasant Hill Stick Around?
Staff turnover at ASPIRE SENIOR LIVING PLEASANT HILL is high. At 60%, the facility is 14 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 86%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Aspire Senior Living Pleasant Hill Ever Fined?
ASPIRE SENIOR LIVING PLEASANT HILL has been fined $14,433 across 1 penalty action. This is below the Missouri average of $33,223. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Aspire Senior Living Pleasant Hill on Any Federal Watch List?
ASPIRE SENIOR LIVING PLEASANT HILL 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.